dentistry journal
Review
Ectopic Permanent Molars: A Review
Samah Alfuriji 1,2, * , Haifa Alamro 1,2 , Jomanah Kentab 3 , Lama Alosail 4 , Linah Alali 3 , Nada Altuwaijri 3
and Rahaf Alalwan 3
Citation: Alfuriji, S.; Alamro, H.;
Kentab, J.; Alosail, L.; Alali, L.;
Altuwaijri, N.; Alalwan, R. Ectopic
Permanent Molars: A Review. Dent. J.
2023, 11, 206. https://doi.org/
10.3390/dj11090206
Academic Editor: Chun Hung Chu
Received: 26 July 2023
Revised: 17 August 2023
Accepted: 18 August 2023
Published: 29 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Dent. J. 2023, 11, 206. https://doi.org/10.3390/dj11090206
1 Department of Preventive Dental Sciences, College of Dentistry, King Saud bin Abdulaziz University for
Health Sciences, P.O. Box 3660, Riyadh 11481, Saudi Arabia; amroh@ksau-hs.edu.sa
2 King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs,
P.O. Box 3660, Riyadh 11481, Saudi Arabia
3 College of Dentistry, King Saud bin Abdulaziz University for Health Sciences,
P.O. Box 3660, Riyadh 11481, Saudi Arabia; kentab109@ksau-hs.edu.sa (J.K.); alali202@ksau-hs.edu.sa (L.A.);
altuwijri196@ksau-hs.edu.sa (N.A.); alalwan030@ksau-hs.edu.sa (R.A.)
4 Department of Periodontics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs,
P.O. Box 22490, Riyadh 11426, Saudi Arabia; alosail007@ksau-hs.edu.sa
* Correspondence: furijis@ksau-hs.edu.sa
Abstract: Ectopic permanent molar is a condition in which the permanent tooth deviates from its
normal path of eruption. The etiology of this eruption anomaly is multifactorial, with both general
and local factors. The principal results suggest that a valid indicator of irreversible consequences
is the degree of impaction of the first permanent molar. Self-correction is most common between
the ages of 7 and 8, after which help may be required. Accordingly, early management can assist
in preventing subsequent potential challenges that could interfere with maintaining a balanced
occlusion. Several variables, including the degree of mesial tilting, the level of root resorption, and
the condition of the second primary molar, may be crucial in choosing the most effective method
of treatment. Interproximal wedging and distal tipping are the two basic therapeutic strategies for
ectopic permanent molars. Additionally, the use of fixed or removable appliances might also be
required. Delaying treatment until a later stage is not recommended because early diagnosis and
treatment are essential for optimal management. This review aims to provide a comprehensive
overview of ectopic permanent molars, including their prevalence, etiologic factors, self-correction
rates, clinical implications for adjacent teeth, and various treatment techniques, that emphasizes the
importance of early detection and intervention in the successful management of ectopic permanent
molars. In addition, it highlights the importance of future research into the contributing variables of
irreversible ectopic molar outcomes.
Keywords: ectopic; impacted; eruption; molar; early treatment; interceptive; tipping; wedging
1. Introduction
An ectopic permanent molar is defined as a local disturbance in the developing
dentition [1]. It can present as an abnormal alteration, deviation, or drifting of the tooth
eruption pathway, which results in the first or second permanent molars erupting in
contact with the distal undercut of the second deciduous molar or first permanent molar,
respectively, instead of erupting into the normal occlusal plane [1]. Nikiforuk defined
ectopic eruption as a condition in which the permanent teeth, because of a deficiency
of growth in the jaw or segment of the jaw, assume a path of eruption that intercepts a
primary tooth, causing its premature loss and producing a consequent malposition of the
permanent tooth [1]. Throughout the literature, the terms ectopic eruption and impaction
have been used interchangeably, and this is due to the fact that an ectopically erupting tooth
might present with various degrees of impaction [2–4]. This can be seen in cases where
the impaction (failure of eruption) of the first permanent molar takes place at the distal
prominence of the second primary molar, and thus studies that have referred to the ectopic
https://www.mdpi.com/journal/dentistry
Dent. J. 2023, 11, 206 2 of 13

eruption as impaction were included. In this literature review, prevalence, classification,

etiology and associated dentoskeletal features, diagnosis, complications and rationale for
treatment, prognosis, treatment, and maintenance are discussed in detail. As the majority of
the literature has focused on exploring the predictive factors and management techniques
of ectopic molars, the present review intends to cover multiple aspects from previous
studies to deliver a comprehensive review of ectopic permanent molars.

2. Prevalence
Most of the studies have focused more on the ectopic eruption of first permanent
molars and fewer studies have reported the prevalence of ectopic second permanent
molars [5].
The prevalence of ectopic first permanent molars ranges between 2 and 6%, with a
higher incidence in the maxilla by 57.5% [6,7]. The total prevalence of disturbances in the
eruption of second permanent molars was around 2.3% [5,8]. The incidence of ectopic
second permanent molars is found to be 1.5%, and they occur more frequently in the
mandible by 92% [5]. Most of the studies found no gender difference between males and
females for both ectopic first and second molars [9]. However, a higher male incidence was
reported among Turkish and Saudi populations [6,10].

3. Etiology and Associated Dentoskeletal Features

There is a general agreement among different authors throughout the literature regard-
ing the etiology of ectopic eruption of permanent molars. It is considered a multifactorial
pathological disorder with both general and local etiological factors, or a combination
of both. General etiological factors include familial tendency and genetics [7,9]. Ectopic
molar eruption has been reported among siblings with a 19.8% prevalence [9]. In addition,
siblings are five times more likely than the overall population to be affected [11]. This
familial tendency offers an opportunity for an early intervention of patients at risk [12]. In
addition, there is an increased prevalence of ectopic molar eruption among cleft lip and
palate patients by 25% and syndromic patients, like those with Turner syndrome and Apert
syndrome, which indicates a possible genetic component of the problem [7,9,13]. In fact,
patients with cleft lip and palate are four times more likely to have an ectopic permanent
molar [7]. According to Ahiko et al., patients with Turner syndrome suffer from a retrog-
nathic maxilla that leads to the ectopic eruption of the first permanent molar accompanied
by resorption of the second primary molar [14]. Multiple local factors have been suggested,
such as the imbalance between the mandibular growth in relation to the eruption of the
first permanent molar. This would force a continued mesial inclination or an abnormal
angulation of eruption of the molar and subsequently its entrapment under the distal bulge
of the second primary molar [9,15–17]. Other local factors include maxillary hypoplasia
and retrognathism, permanent molar macrodontia or delayed calcification, an unfavorable
shape of the second primary molar crown, insufficient maxillary tuberosity growth, and
crowding [9,15–18]. Moreover, an iatrogenic factor has been proven to cause an ectopic
eruption of the first permanent molar. According to Croll et al., a lack of marginal adapta-
tion of stainless-steel crowns placed on the second primary molars hinders the eruption
of the first permanent molar. This failure to properly trim and contour the stainless-steel
crown would impact adjacent teeth and cause malocclusion [19] (Figure 1).
Numerous studies have associated the ectopic eruption of first and second permanent
molars with other dental disturbances [20–22]. Baccetti established a significant association
among disturbances in the eruption of both first and second permanent molars and palatally
displaced canines (30.76%) [20]. Another study found that 23% of patients had an ectopic
maxillary first permanent molar in relation to the ectopic eruption of the maxillary ca-
nine [21]. This suggests that an ectopic eruption of maxillary molars and a pathological root
resorption of the second primary molar leads to a higher risk of ectopic maxillary canines
and resorption of maxillary permanent lateral and/or central incisors [21]. Additionally, an-
 Dent. J. 2023, 11, 206 3 of 13

Dent. J. 2022, 10, x FOR PEER REVIEW

other study also showed that ectopic maxillary canines appear more frequently in children
with a primary diagnosis of maxillary first permanent molar eruption disturbances [22].

Figure
Figure 1. Ectopic
1. Ectopic eruption
eruption of the right
of the maxillary maxillary right first
first permanent molarpermanent molar
due to improper due to imp
marginal
adaptation
adaptation of stainless-steel
of the the stainless-steel crown
crown placed placed
on the onprimary
second the second primary ofmolar.
molar. (Courtesy Dr. (Co
H. Alamro.)
Alamro.)
4. Classification
Numerous
Throughout studiesthe
the literature, have associated
ectopic thefirst
eruption of the ectopic eruption
permanent molar has ofmany
first and s
classifications based on several factors, such as spontaneous correction
nent molars with other dental disturbances [20–22]. Baccetti established of its position, its a
effect on the second primary molar, and severity [23]. According to Young, ectopic eruption
sociation among disturbances in the eruption of both first and second perm
can be either reversible or irreversible [23]. He introduced the terms jump and hold. Jump,
and
or palatallyisdisplaced
self-correcting, canines
where the first permanent (30.76%) [20].
molar will Another correct
spontaneously studyitselffound
and that 2
erupt
had in anitsectopic
normal position
maxillary[23]. In contrast,
first hold is the
permanent irreversible
molar type andto
in relation leads
thetoectopic
a e
more permanent impaction of the molar with worse consequences [23]. Barberia-Leache
maxillary canine [21]. This suggests that an ectopic eruption of maxillary
et al. proposed another classification based mainly on the resorption severity effect on
pathological
second root resorption
primary molars ofLikewise,
(Table 1) [7,24]. the second primary
Harrison molar
and Michal leadsectopic
classified to a higher
maxillary canines and resorption of maxillary permanent lateral and/or c
eruption according to impaction (Lock’s) severity, using the marginal ridge of the second
primary molar as a reference on bitewing radiographs (Table 1) [25]. On the other hand,
[21]. Additionally, another study also showed that ectopic maxillary canine
there is a lack of classification of ectopically erupting second and third molars throughout
frequently
the literature. in children with a primary diagnosis of maxillary first permane
tion disturbances [22].
Table 1. Classifications of ectopic first molars.

Barberia-Leache ’s Classification4.(Based
Classification
on the effect on second primary molar) *
Grade 1 Grade 2 Grade 3 Grade 4
Mild Throughout
Moderate the literature, the ectopic eruption Very
Severe of the
severefirst perman
Dent.
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Dent.
Dent. 2022,
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10, xFOR
Limited
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xxFORPEER
FOR
PEER REVIEW
resorption
PEER to
REVIEW
REVIEW
PEER REVIEW 4 4ofof 1414
4414
of
of 14
the cementum or with
many classifications based
Resorption of the dentine without
on several factors, suchResorption
Resorption of the distal root leading
as spontaneous
that affects correct
the mesial root of the
minimum dentine tion,pulp
its exposure
effect on the second primary molar, and severity
to pulp exposure [23]. According to
second primary molar
penetration
eruption can be either reversible or irreversible [23]. He introduced the te
hold. Jump, or self-correcting, is where the first permanent molar will spon
rect itself and erupt in its normal position [23]. In contrast, hold is the irr
and leads to a more permanent impaction of the molar with worse cons
Barberia-Leache et al. proposed another classification based mainly on the
verity effect on second primary molars (Table 1) [7,24]. Likewise, Harriso
classified ectopic eruption according to impaction (Lock’s) severity, using
Harrison
Harrison
Harrison and
and
Harrison Michal’s
and Michal’s
Michal’s
and ridge
Classification
Classification
Classification
Michal’s Classification of on
(based
(based the
(basedon
(basedon second
severity
on
severity
severity ofofprimary
severity the
of
the
of the
the lock
lock molar
using
lock
lock using
using
using as a reference
bitewing
bitewing
bitewing
bitewing on* *bitewing
radiograph)
radiograph)
radiograph)
radiograph) ** radiographs
Normal
Normal
Normal
Normal On the otherMinimalhand,
Minimal
Minimal
Minimal there
lock
locklock
lock is a lack of classificationSevere
ofSevere
ectopically
Severe
Severe lock erupting se
lock
lock
lock
Impacted
molars
Impacted
Impacted less
throughout
Impacted
less lessthan
than
less half
than the
half
than the
half
the
half the width
literature.
the
width ofofof
width
width the
of
thethe Impacted
the Impacted
Impacted
Impacted more
more
more
more than
thanthan
than the
the width
the ofofof
width
width
the width the
of
the the
the
No
NoNosign
sign
No ofofof
sign
sign impaction
of impaction
impaction
impaction distal
distal marginal
distal
marginal
distal ridge
marginal
ridge
marginal ofofof
ridge
ridge the
of
the second
the
second
the pri-
second
pri-
second pri- distal
pri-distal marginal
distal
marginal
distal ridge
marginal
ridge
marginal ofofof
ridge
ridge the
of
the second
the pri-
second
second
the pri-
pri-
second pri-
mary
mary
mary
mary molar
molar
molar
Table 1. Classificationsmolar
of ectopic first molars. mary
marymary
mary molar
molar
molar
molar

Barberia-Leache ’s Classification (Based on the effect on second primary molar) *

Grade 1 Grade 2 Grade 3 Gra
 Dent. J. 2023, 11, 206 4 of 13

Table 1. Cont.
Harrison
arrison and and and
Michal’s
Harrison Michal’s Classification
Classification
Michal’s (based on
Classification(based on severity
severity
(based of the
on of the
lock
severity oflock
using using
thebitewing
lock bitewing
using radiograph)
radiograph)
bitewing *
radiograph)* *
Normal
Harrison Normal
and Normal
Michal’s severity Minimal
Classification (based on Minimal lock
of theMinimallocklock
lock using bitewing radiograph) * Severe Severe locklock
lockSevere
Normal Impacted less Minimal
than lock
half theofwidth ofImpacted
the Severe lock
Impacted less than
Impacted half the
less width
than half thethewidth of theImpacted
more more
than
Impacted than
the width
more theof
than width of the
thewidth
the of
Impacted less than half the width of
No sign
No of
No sign of impaction
Nosign
impaction
sign of impaction
of impaction
distal
distal marginal marginal
distalridge
the
ridge
of
marginal
distal
of
theridge the
second
marginal
second
ofofpri-
ridge the pri- distal
Impacted
distalpri-
thesecond
more
marginal marginal
than
distalridgethe ridge
width ofof
of theridge
marginal the
the
second second
distal
of pri- pri-
the second
marginal ridge of the second primary molar
mary mary
molar
second molar
mary molar
primary molar mary mary
molar molar
mary molar

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5. Diagnosis
5. Diagnosis
5. Diagnosis
5. Diagnosis
Ectopic
EctopicEctopic
eruption eruption
Ectopiceruptionanisasymptomatic
anisasymptomatic
is eruption anisasymptomatic anomaly
anomaly
an asymptomatic that
anomaly
that isisusually
anomaly usually diagnosed
that that
is usually
diagnosed
is usually as anasincidental
diagnosed as anasinci
an inci-
diagnosed an
finding
dental
dental finding during
finding
dentalduring clinical
during
clinical
finding examination
duringclinical
examination
clinical or radiographic
examinationor radiographic
examination assessment.
or radiographic assessment.
or radiographic It should
assessment. be
It should
assessment. suspected
It should
beItsus- be sus
should be
when
pected there
when is greater
there isthan
greater6 months
than 6delay
months of eruption
delay of compared
eruption with
comparedits contralateral
with its contrala
pected when there when
pected is greaterthere than 6 months
is greater thandelay of eruption
6 months delay of compared
eruptionwith its contrala-
compared with its cont
molar, when the first permanent molar is mesially angulated, or when asymmetry exists in
teralteral
teral molar, molar,
when when
the first the first
permanent permanent
molar ismolar
mesiallyis mesially
angulated, angulated,
or when orasymmetry
when asymmetry
the molar eruption [10,26]. Different radiographic techniques can be used to determine the asymm
molar, when the first permanent molar is mesially angulated, or when
exists
exists in
ectopic
in
theexists
molar the
eruption,
molar
ineruption
thesuch eruption
molar as[10,26].
eruption
bitewing
[10,26].
Different Different
[10,26].
radiographs,
radiographic
radiographic
Different techniques
techniques (OPG)
radiographic
orthopantomography can can betoused
beradiographs,
techniques usedcan de- to det
be used
termine
termineor the the ectopic
ectopic
termine
cone-beam eruption,
the eruption,
ectopic
computed such assuch
eruption,
tomography bitewingas bitewing
such
(CBCT), as with radiographs,
radiographs,
bitewing beingorthopantomography
orthopantomography
radiographs,
the latter theorthopantomography
most precise one (OPG
(OPG) (O
radiographs,
radiographs,
among or
radiographs,
the or
cone-beam
techniquescone-beam
or computed
cone-beam computed
used [10]. tomography
computed tomography
(CBCT),
In contrast,tomography
OPG (CBCT),
with
radiographs with
theonly
(CBCT), latterthe
with latter
being being
themore
the latter
deliver no most the mos
being the
precise
precisethan 10%one
one precise
among of theamong
the radiationthe
techniques techniques
doseused
produced used
[10]. Inby[10]. In
contrast,
CBCT contrast,
andOPG can
one among the techniques used [10]. In contrast, OPG radiographs only OPG
radiographs
be used radiographs
as a only
reliable only
deliver
tool deliver
no deliv
for no
measuring
more
more than 10% than
more tooth
10%
ofthan angulation
of
the radiationthe
10% of the [26].
radiation
dose Thus,
dose
produced
radiation it is a
doseby viable
produced tool
by
CBCT and
produced in
CBCTdiagnosing
bycan and
CBCT can
be used ectopic
and can be eruption
used
as abe as
reliable a
used as [26].
reliable
tool too
a reliable
Early
for measuring radiographic
for measuring
tooth toothassessment
angulation angulation
[26].should
Thus,[26].be
it a
Thus,
is priority
a it is
viable in
a 5–7-year-old
viable
tool in
for measuring tooth angulation [26]. Thus, it is a viable tool in diagnosing ectopic tool inchildren
diagnosing diagnosing [9].
ectopic This helps
ectopic
eruption eruption
erup
to detect, intervene
[26].radiographic
EarlyEarlyradiographicin, and avoid
assessmentirreversible locking of the permanent molar [10]. Since
[26]. Early [26]. assessment
radiographic should should
assessment be ashould be a be
priority priority in 5–7-year-old
ina5–7-year-old
priority childrenchildren
in 5–7-year-old This[9]. This
[9].children [9].
the chances of self-correction are lower in children above the age of 7, a prompt diagnosis
helps
helps toof detect,to
helps detect,
intervene intervene
to isdetect, in, and in,
avoidand avoid
irreversible irreversible
locking locking
of the of the
permanent permanent
molar molar
[10]. [10]
such cases criticalintervene
to ameliorate in, and avoid irreversible
the prognosis and palliate locking of the permanent
the consequences of the molar
Since
Since the the
chances
Since chances
of
the chances of self-correction
self-correction of are lower
self-correction are lower
in
are in
children
lower children
above
in
failure of eruption [10,26]. Otherwise, if not treated, it can incite various pathological
above
the
children age the
above of age
7,
the a of 7,ofa 7,
prompt
age promp
a pro
diagnosis
diagnosis of such
diagnosis
conditions of such
cases is cases
critical is critical
to to
ameliorate ameliorate
the the
prognosis prognosis
and and
palliate
[26]. of such cases is critical to ameliorate the prognosis and palliate the conseque palliate
the the consequences
consequences
of the
of the failure failure
ofoftheeruptionof eruption
failure [10,26].
of eruption [10,26].
Otherwise, Otherwise,
[10,26]. if notif treated,
if not treated,
Otherwise, it can
not it can
incite
treated, incite
itvarious various
can incite pathologi- pathologi
various patho
6.
cal Complications
cal conditionsconditions
cal [26]. and
[26].
conditions [26]. Rationale for Treatment
Untreated ectopic molars will result in a local disturbance of eruption and may lead to
several
6. Complications harmful
andconsequences,
6. Complications
6. Complications and and
Rationale Rationale
for leading fortoTreatment
Treatment
Rationale impaired
for Treatment function and appearance [10]. Pain and
infection around the second primary molar are often common complications resulting from
Untreated Untreated
ectopic
Untreated ectopic
molars molars
will molars willin
result result
a local in disturbance
a local disturbance
of eruptionof eruption
and may and maymay
lead lead
an ectopically eruptingectopic first permanent will
molar result
[24]. inAsathe local disturbance
severity of these of eruption
complications and
to several
to several harmful harmful
to several
increases, it leads harmfulconsequences,
consequences,
to atypical leadingleading
consequences,
pathological to impaired
leading to impaired
resorption tofunction
impaired
and
function
and and
appearance
function
a premature
appearance
lossandof the[10]. Pain
appearance
second
[10].[10].
Pain
and
and infection infection
and
primary around around
infection
molar the second the
aroundThis
[10,24,26]. second
primary
the resultsprimary
second molar
inprimary
mesialmolar
are oftenmolarare
tipping, often
common
are common
often
migration, common complications
complications resulting
complications
and rotation of the resulting
resu
from
from anfirst an ectopically
ectopically
from
permanent molar,erupting
an erupting
ectopically afirst erupting
deficiency firstinfirst
permanent permanent
molar
length[24].
archpermanent molar
in the [24].
Asaffected
molar Asquadrant,
the[24]. the
As severity
severity of these
the ofcompli-
severity
crowding these compli
ofofthese com
cations
cationstheincreases,increases,
corresponding
cationsitincreases,
leads it
arch leads
to segment,
atypical to atypical
it leads unilateral
pathological
to atypical pathological
shifting resorption
of the maxillary
resorption
pathological and and a
molarand
a premature
resorption premature
towards
a loss a of the lossthe
loss
class
premature of o
secondII position,
second
primary and
primary
molar the subsequent
molar
[10,24,26]. [10,24,26].
This loss of
This
results space
results
in for
mesial inthe eruption
mesial
tipping,
second primary molar [10,24,26]. This results in mesial tipping, migration, and rotati of
tipping, the
migration, second
migration,
and premolar,
and
rotation rotation
of o
the firstpotentially
the first
permanent leading
permanent
the first molar, to its
permanent impaction
amolar,
deficiency
molar, or
aindelayed
a deficiency arch in
deficiency eruption
arch
length in
in arch [24,27].
length
the in Moreover,
the
in affected
affected
length supraeruption
quadrant,
the quadrant,
affected crowding
quadrant,of
crowding
crow
the opposing
of the molar results in distortion of the curve of Spee and potentially leads to occlusal
of the corresponding arch segment, unilateral shifting of the maxillary molar towaa
corresponding
of the corresponding arch arch
segment, segment,
unilateral unilateral
shifting shifting
of the of the
maxillary maxillary
molar molar
towards towards
a
interference and multiple other orthodontic problems [10,24,26,27]. Similarly, an ectopically
class II position,
class II erupting
position,
class and and
thepermanent
II position, the subsequent
subsequent
and the lossmight loss loss
of space
subsequent offorspace
thespacefor theforeruption
eruption ofrisk of the
theofsecond second
premolar, premolar
second molar lead toofan increased the eruption rootofresorption,
the second prem
potentially
potentially leading
potentially
especially
leading
to
cervicalits
leadingto
impactionits impaction
or delayed
to its impaction
root resorption
or delayed
of the first eruption
or permanent eruption
[24,27].
delayed eruption [24,27].
Moreover, Moreover,
[24,27].
molar, caries and
supraeruption
supraeruption
Moreover,
periodontal supraerup
of the
of the opposingof opposing
problems, themolar
opposing
difficultiesmolar
results molar
in results
treating in
in distortion
results distortion
deep ofdistortion
inbite, the of the
curve
follicular curve
ofofcysts,
Spee
the ofand
curve Spee and and
ofpotentially
Spee
malocclusion, potentially
leads toleadslea
potentially
pericoronal to
inflammation, and pain [8].
Dent. J. 2023, 11, 206 5 of 13

7. Prognosis
It has been documented that one-third of the cases remain locked after 7 years of
age [26]. Therefore, through the ages of 7 to 8 years, an ectopic eruption of the first
permanent molar is considered irreversibly locked. An additional important time milestone
is when the maxillary molar reaches the level of the mandibular occlusal plane [10]. During
the discussed period, an intervention is directed to establish proper vertical control and
avoid supraeruption [10]. Various research has also explored some predictive factors for
irreversible outcome. Dabbagh et al. analyzed the potential radiographic and clinical
predictors for the irreversible outcome [28]. They reported that the extent of the impaction
of the first permanent molar measured on bitewing radiographs was directly correlated
with the irreversible consequence, and it was the most reliable predictor among the other
assessed predictors, such as the degree of resorption, the amount of enamel ledge, the
angulation of the molar, and the severity of the lock [26,28]. Also, it has been reported that
bilateral ectopic eruption in males with an increased amount of impaction is positively
associated with the irreversible type [28]. Bjerklin and Kurol had reported that the eruptive
angulation and crown width of the first permanent molar were two critical factors in
the outcome of ectopic eruptions [17]. However, a more recent study suggested that
the eruptive angulation was interrelated with the onset of ectopic eruption; however, no
significant difference was detected regarding the irreversible outcome [28]. Other possible
reported factors that may lead to eruptive angulation are differences in bone-tooth size
or some disturbances in the chronology of bone growth at the tuberosity area in relation
to the calcification and eruption of the first permanent molar [10]. The genetic factor has
also been associated with ectopic molars [10]. In addition, dental factors like caries or
unfavorable morphology of the second primary molar might contribute to this eruption
anomaly [26]. These conflicting results emphasize the importance of further investigations
into the predictors for the irreversible outcome [26].

8. Treatment
Early intervention can help in preventing further complications that could affect the
establishment of a balanced occlusion [29]. Therefore, delaying the treatment to a later
stage is not advisable. The treatment of ectopic molars and the time of intervention depend
on several factors [30]. Although previous studies have agreed that by the age of seven 66%
of ectopic molars are self-corrected, others have stated that spontaneous eruption will not
happen if the first permanent molar is not fully erupted at that age [4,29]. Therefore, the
initiation of the treatment should be started immediately after the diagnosis is established.
For those who are diagnosed before the age of 8, six months follow-up is recommended to
allow time for self-improvement [7]. However, other studies have reported self-correction
of ectopic maxillary first permanent molars after the age of 9 years in 71% of patients [28].
This might be a result of the resorption of the primary first molar and mesial drifting of the
primary second molar, which allows the permanent first molar to move freely. This must
be taken into consideration because unnecessary intervention might increase the risk of
infection and accelerate the loss of the primary tooth. Moreover, overtreatment might be a
waste of time and money for the patient and the practitioner. Thus, when the outcome is
uncertain, delaying interceptive treatment is a possible option [28].
Several factors such as patient’s age, the severity of impaction, the degree of mesial
tilting, the level of root resorption, and the status of the second primary molar could play
an important role in determining the possible treatment options [8,25]. Generally, two
main techniques are used for the management of ectopic permanent molars: interproximal
wedging and distal tipping [23,30].

9. Ectopic First Permanent Molars

Based on the severity grading described by Barberia-Leache et al., in grade 1 ectopic
molars the patient should be under observation and scheduled for a follow-up to allow
spontaneous correction [7,24]. As the severity increases, active treatment is required and
 main techniques are used for the management of ectopic permanent molars: interproximal
wedging and distal tipping [23,30].

9. Ectopic First Permanent Molars

Based on the severity grading described by Barberia-Leache et al., in grade 1 ectopic
Dent. J. 2023, 11, 206 6 of 13
molars the patient should be under observation and scheduled for a follow-up to allow
spontaneous correction [7,24]. As the severity increases, active treatment is required and
can be achieved through multiple techniques [7]. In grade 2 mild cases, interproximal
can be achieved
wedging could bethrough
achieved multiple
using antechniques [7]. In grade
elastic separator 2 mild
or Kesling cases, interproximal
separator [7], while in
grade 3, the separation technique is not sufficient, so distal tipping of ectopic[7],
wedging could be achieved using an elastic separator or Kesling separator while in
permanent
grade 3, the separation technique is not sufficient, so distal tipping of ectopic
molars using an active appliance is required [7]. This could be achieved using a fixed or permanent
molars using
removable an active
appliance [7].appliance
In grade is4, required [7]. This
severe ectopic couldcan
eruption be achieved usingroot
lead to severe a fixed
re-
or removable appliance [7]. In grade 4, severe ectopic eruption can lead
sorption of the second primary molar and space loss; therefore, extraction of the primary to severe root
resorption
molar of the second[23].
is recommended primary molar and space
The consequences loss; therefore,
of second primaryextraction
molar spaceof the
lossprimary
can be
molar is recommended [23]. The consequences of second primary
avoided by placing a space maintainer or regainer, depending on the amount of spacemolar space loss can
be avoided by placing a space maintainer or regainer, depending on the amount
loss, to ensure the second premolar eruption is in its correct position [7]. In cases of con- of space
loss, to ensure the second premolar eruption is in its correct position [7]. In cases of
genitally missing second premolars, extracting the second primary molar and allowing
congenitally missing second premolars, extracting the second primary molar and allowing
the permanent molar to erupt mesially and close the space is suggested [7].
the permanent molar to erupt mesially and close the space is suggested [7].
9.1.
9.1. Interproximal
Interproximal Wedging
Wedging
In cases where
In cases where the the first
firstpermanent
permanentmolar
molarisisminimally
minimally or or moderately
moderately impacted
impacted on
on the
the distal
distal aspect
aspect of of
thethe second
second primarymolar,
primary molar,interproximal
interproximalwedging
wedgingisischosen
chosen [7,30].
[7,30]. This
This
option utilizes a wide range of separation techniques such as an elastic separator
option utilizes a wide range of separation techniques such as an elastic separator (Figure (Figure 2),
2),
softsoft brass
brass wire,
wire, oror a springseparator
a spring separator[7,30,31].
[7,30,31]. Disking
Disking the
the adjacent
adjacent maxillary
maxillary second
second
primary
primary molar
molar using
using aa 169
169 LL carbide
carbide bur
bur at
at high
high speed
speed can
can also
also relieve
relieve the
the impaction
impaction of of
the permanent successor [30]. The soft brass wire separation technique
the permanent successor [30]. The soft brass wire separation technique was introduced was introduced by
Levitas
by Levitasin 1964. It was
in 1964. frequently
It was utilized
frequently as other
utilized techniques
as other like elastic
techniques separators
like elastic were
separators
not
were not introduced yet. However, the softness of the wire was its main disadvantage cre-
introduced yet. However, the softness of the wire was its main disadvantage and and
ated difficulty
created in the
difficulty in passage
the passagebetween the second
between primary
the second molar
primary and the
molar andectopic first per-
the ectopic first
manent
permanent molar [32,33].
molar [32,33].

Figure
Figure 2.2.An
An8-year-old
8-year-oldpatient
patientwith
withectopic
ectopicmandibular
mandibularfirst
firstpermanent
permanentmolars.
molars. (A).
(A).Pre-treatment
Pre-treatment
lateral and occlusal clinical pictures showing the ectopic eruption of right first permanent molar
lateral and occlusal clinical pictures showing the ectopic eruption of right first permanent molar
against the stainless-steel crown of the primary second molar (iatrogenic), and ectopic eruption of
against the stainless-steel crown of the primary second molar (iatrogenic), and ectopic eruption of the
the left first permanent molar against the crown of primary second molar. (B). Pre-treatment pano-
left first
ramic permanent
radiograph molar against
confirming the crown
the clinical of primary
findings. second molar. (B).
(C). Post-treatment Pre-treatment
lateral and occlusalpanoramic
clinical
pictures showing the correction on the path of eruption of lower permanent molars using anpictures
radiograph confirming the clinical findings. (C). Post-treatment lateral and occlusal clinical elastic
showing the
separator correction
placed betweenonthe
thesecond
path ofprimary
eruptionmolars
of lower
andpermanent molars using
the first permanent an elastic
molars separator
replaced every
placed
two between
weeks. the second
(Courtesy of Dr.primary molars and the first permanent molars replaced every two weeks.
S. Alfuriji.)
(Courtesy of Dr. S. Alfuriji.)
9.2. Distal Tipping
9.2. Distal Tipping
In severe cases, distal tipping is the preferred option with or without the extraction
In severe cases, distal tipping is the preferred option with or without the extraction
of the second primary molar. Multiple fixed or removable appliances are used in the distal
of the second primary molar. Multiple fixed or removable appliances are used in the
distal tipping technique [7,30]. Examples are a removable appliance with active cantilever
springs [34], the Humphrey appliance, the Halterman appliance (Figures 3 and 4) [35],
sectioned wire with an open coil spring, a k-loop, and Croll’s appliance (Figure 5) [4,30].
Some authors used these appliances along with surgical exposure of the first permanent
molar for better accessibility to button bonding [36].
 tipping technique [7,30]. Examples are a removable appliance with active cantilever
tipping technique [7,30]. Examples are a removable appliance with active cantilever
springs [34], the Humphrey appliance, the Halterman appliance (Figures 3 and 4) [35],
springs [34], the Humphrey appliance, the Halterman appliance (Figures 3 and 4) [35],
sectioned wire with an open coil spring, a k-loop, and Croll’s appliance (Figure 5) [4,30].
sectioned wire with an open coil spring, a k-loop, and Croll’s appliance (Figure 5) [4,30].
Dent. J. 2023, 11, 206 Some authors used these appliances along with surgical exposure of the first permanent
7 of 13
Some authors used these appliances along with surgical exposure of the first permanent
molar for better accessibility to button bonding [36].
molar for better accessibility to button bonding [36].

Figure 3. Ectopic maxillary first permanent molar with Halterman appliance to tip the first molar
Figure 3.3. Ectopic
distally
maxillary first permanent molar with Halterman appliance to tip the first molar
in a 5-year-old girl. (A). Pre-treatment radiograph showing maxillary left ectopic permanent
distally 5-year-old
molar. (B). Bitewinggirl.
in a (A). Pre-treatment
radiograph radiograph
during appliance showing
treatment. (C).maxillary left ectopic permanent
Clinical photograph of the Halter-
molar.
molar. (B).
man(B). Bitewing
Bitewing
appliance radiograph
radiograph
6 weeks during
later.during appliance treatment.
appliance treatment.
(D). Post-treatment (C). Clinical
(C). showing
radiograph photograph
satisfactoryof
Clinical photograph of the
the Halter-
Halter-
eruption of the
man
man appliancemolar.
appliance
permanent 66 weeks
weeks later. (D).
later.
(Courtesy (D). Post-treatment
of Post-treatment
Dr. Abu-Husseinradiograph
radiograph showing
showing
M, permission satisfactory eruption
satisfactory
granted.) eruption ofof the
the
permanent molar.
permanent molar. (Courtesy
(Courtesy ofof Dr.
Dr. Abu-Hussein
Abu-Hussein M,M, permission
permission granted.)
granted.)

Figure 4. A case of an 8-year-old patient with a bilateral ectopic eruption of the maxillary first
permanent molars. (A). Occlusal photograph before the treatment. (B). The right side showed a
Figure 4. A case of an 8-year-old patient with a bilateral ectopic eruption of the maxillary first per-
moderate
Figure 4. Adegree ofan
case of impaction and was treated a using an elastic
ectopicseparator for distal wedging of per-
#16.
manent molars. (A).8-year-old patient
Occlusal photograph withbefore
bilateral
the treatment. eruption of right
(B). The the maxillary first
side showed a mod-
manent
The left molars.
side (A).
showed Occlusal
a severe photograph
degree of before
impactionthe treatment.
and was (B).
treated The right
using a side showed
Halterman
erate degree of impaction and was treated using an elastic separator for distal wedging of #16. The a mod-
appliance
erate
for leftdegree
distal
side of impaction
tipping
showedof #26. anddegree
(C,D).
a severe was treated
Occlusal using anand
photographs
of impaction elastic
wasseparator
after the for distal
treatment,
treated usingand wedging
the overallof
a Halterman #16. The for
treatment
appliance
leftdistal
side showed
duration was 3 a severe
months. (E).degree of
Panoramicimpaction
radiographand was
before treated
the using
treatment a Halterman
shows appliance
complete resorption
tipping of #26. (C,D). Occlusal photographs after the treatment, and the overall treatment for
distal tipping of #26. (C,D). Occlusal photographs after the treatment, and the overall treatment
of the disco-buccal root of the maxillary second primary molars. (F). Panoramic radiograph after the
treatment. (G). Illustration of the Halterman appliance. (Courtesy of Dr. H. Alamro.) (Illustrations by
Dr. Linah Alali.).
 Dent. J. 2022, 10, x FOR PEER REVIEW 8 of 14

Dent. J. 2023, 11, 206
duration was 3 months. (E). Panoramic radiograph before the treatment shows complete resorption
of the disco-buccal root of the maxillary second primary molars. (F). Panoramic radiograph after the
8 of 13
treatment. (G). Illustration of the Halterman appliance. (Courtesy of Dr. H. Alamro.) (Illustrations
by Dr. Linah Alali.).

Figure5.5.Bilateral
Figure Bilateralectopic
ectopicmaxillary
maxillaryfirst
firstpermanent
permanentmolars
molars with
withcemented
cemented modified
modified Croll’s
Croll’s appliance
appli-
ance to tip the first molars distally. (A). Pre-treatment clinical photograph showing bilateral ectopic
to tip the first molars distally. (A). Pre-treatment clinical photograph showing bilateral ectopic
eruption of the maxillary molars. (B). Pre-treatment radiograph. (C). Modified Croll’s appliance af-
eruption of the maxillary
ter cementation. molars. (B).
(D). Post-treatment Pre-treatment
radiograph showingradiograph. (C). Modified
normal eruption Croll’s
of maxillary appliance
permanent
after cementation. (D). Post-treatment radiograph showing
molars. (Courtesy of Dr. Ambriss B, permission granted.) normal eruption of maxillary permanent
molars. (Courtesy of Dr. Ambriss B, permission granted.)
10. Ectopic Second Permanent Molars
10. Ectopic Second Permanent Molars
The treatment of ectopic second permanent molars differs from first molars in terms
Theneed
of the treatment of ectopicorthodontic–surgical
for a combined second permanent molars approach.differs fromwhere
In cases first molars
the molar in terms
is
ofpartially
the need impacted, distal tipping through fixed appliances can be used (Figure 6). In situ- is
for a combined orthodontic–surgical approach. In cases where the molar
partially impacted, distal tipping
ations of complete impaction, through
surgical fixedisappliances
uprighting the treatment canofbe usedwith
choice (Figure 6). In
or with-
situations
out removal of the third molars’ buds (Figure 7). The overall long-term prognosis of this or
of complete impaction, surgical uprighting is the treatment of choice with
without
procedureremoval
is goodof[37].
the In
third
casesmolars’
where buds (Figure
the second 7). The overall
permanent molar islong-term
ectopicallyprognosis
erupt-
ofing,
thissurgical
procedureexposure is performed followed by orthodontic treatment molar
is good [37]. In cases where the second permanent is ectopically
like using elastic
erupting,
separatorssurgical exposure
[38]. Titanium is performed
screw implants can followed
also beby orthodontic
used as a source treatment
of anchoragelike using
to
elastic
guide separators
the second[38]. Titanium
permanent screw
molar intoimplants canposition.
the correct also be used as molars
If third a sourceareofpresent,
anchorage
Dent. J. 2022, 10, x FOR PEER REVIEW 9 of 14
tothey
guide the second
should permanent
be extracted molar
first before into placement
screw the correct[39].
position. If third molars are present,
they should be extracted first before screw placement [39].

Ectopic
Figure6.6.Ectopic
Figure maxillary
maxillary left left second
second permanent
permanent molar molar (#27) erupted
(#27) erupted against
against the the first permanent
first permanent
molar
molar(#26).
(#26).(A).
(A).Pre-treatment
Pre-treatment radiograph showing
radiograph the impaction
showing of #27ofagainst
the impaction #26 causing
#27 against a cer- a cervical
#26 causing
vical root resorption on the distal surface of the first molar. (B). Occlusal photograph with partial
eruption of #27. (C). Illustration of the appliance used to erupt #27, a fixed edgewise appliance with
an open coil spring to tip and erupt #27 distally (illustrations by Dr. Linah Alali). (D). Progress ra-
diograph with an erupted and aligned #27 with an obvious cervical root resorption on #26. (E). Oc-
clusal photograph after alignment of #27. (Courtesy of Dr. S. Alfuriji.)
Dent. J. 2023, 11, 206 9 of 13

Figure 6. Ectopic maxillary left second permanent molar (#27) erupted against the first permanent
molar (#26). (A).on
root resorption Pre-treatment radiograph
the distal surface showing
of the first molar.the
(B).impaction of #27 against
Occlusal photograph #26partial
with causing a cer-
eruption
vical root resorption on the distal surface of the first molar. (B). Occlusal photograph with partial
of #27. (C). Illustration of the appliance used to erupt #27, a fixed edgewise appliance with an open
eruption of #27. (C). Illustration of the appliance used to erupt #27, a fixed edgewise appliance with
coil spring to tip and erupt #27 distally (illustrations by Dr. Linah Alali). (D). Progress radiograph
an open coil spring to tip and erupt #27 distally (illustrations by Dr. Linah Alali). (D). Progress ra-
with an erupted
diograph with an and aligned
erupted and #27 with#27
aligned anwith
obvious cervicalcervical
an obvious root resorption on #26.
root resorption on (E).
#26.Occlusal
(E). Oc-
photograph after alignment of #27. (Courtesy of Dr. S. Alfuriji.)
clusal photograph after alignment of #27. (Courtesy of Dr. S. Alfuriji.)

Figure 7. Ectopic mandibular left second permanent molar (#37) with impacted third molar (#38).
(A,B). Occlusal photograph and panoramic radiograph before the treatment of the second molar (#37).
(C). Occlusal photograph 11 days post-surgical uprighting of the second molar (#37) and extraction
of third molar (#38). (D). Panoramic radiograph after the treatment. (Courtesy of Dr. S. Alfuriji.)

11. Novel Devices

Orthodontics is a developing field, with new devices and modifications of old ones
emerging to achieve the best treatment outcomes. One of the latest introduced devices is the
piston elastic, which functions through the distal tipping concept (Figure 8). Unlike other
conventional methods, this device does not require impression taking or any laboratory-
related work, which saves time and cost. However, the piston elastic is attached to the
occlusal surface, and it can dislodge during mastication [40]. Other existing devices were
modified to enhance their characteristics such as the rect-spring, which was introduced in
2014. The modification aimed to overcome the weak retention on mesially tilted molars
(Figure 9). However, each device comes with its own limitations, and this device is not
recommended for molars with severe tilting. Also, it can cause an anterior open bite due
to unfavorable distal protrusion. Careful planning is crucial before deciding the correct
treatment modality for any ectopic molar case [29,41]. A summary of different treatment
modalities and a treatment decision flowchart are included (Table 2, Figure 10).
 duced in 2014. The modification aimed to overcome the weak retention on mesially tilted
molars (Figure 9). However, each device comes with its own limitations, and this device
is not recommended for molars with severe tilting. Also, it can cause an anterior open bite
due to unfavorable distal protrusion. Careful planning is crucial before deciding the cor-
Dent. J. 2023, 11, 206
rect treatment modality for any ectopic molar case [29, 41]. A summary of different 10
treat-
of 13
ment modalities and a treatment decision flowchart are included (Table 2, Figure 10).

Figure 8.
Figure Designofofthe
8.Design thepiston
pistonelastic.
elastic. (A),
(A), TheThe piston
piston elastic
elastic is bonded
is bonded on the
on the occlusal
occlusal surface
surface of
of the
the ectopic
ectopic molar,
molar, withwith its hook
its hook pointing
pointing distally;
distally; the elastic
the elastic is placed
is placed as demonstrated.
as demonstrated. The The angle
angle be-
tween thethe
between straight part
straight of of
part thethe
wire
wireand
andthe hook
the hook should
shouldbebeless
lessthan
than9090totoavoid
avoidthe
theelastic
elasticslipping.
slipping.
(B).
(B). Device
Device activation
activation resulting
resulting inin distal
distal movement
movementof of the
the ectopic
ectopicmolar.
molar. (Courtesy
(Courtesyof ofDr.
Dr. Kim
KimIH,IH,
permission
permission granted.)
granted.)

Figure
Figure 9.
9. Comparison
Comparison between
between the
the regular
regular rect-spring
rect-spring and
and the
the modified
modified rect-spring
rect-spring in
in the
the passive
passive
(A,B) and the engaged states (C,D). (Courtesy of Dr. Song MS, permission granted).
(A,B) and the engaged states (C,D). (Courtesy of Dr. Song MS, permission granted).

Table 2. Comparison between different treatment modalities.

Severity of Chair Side Laboratory Patient Treatment

Treatment Modalities Cost
Impaction Time Work Discomfort Duration
Elastic separator [35] Mild to moderate ↓ 5 ↑ ↓ ↓
Soft brass wire separator [37] Mild to moderate ↓ 5 ↑ ↓ ↓
Spring separator Mild to moderate ↓ 5 ↑ ↓ ↓
√
Humphrey appliance Moderate to severe ↑ ↓ ↑ ↓
√
Halterman appliance [35] Moderate to severe ↑ ↓ ↑ ↓
√
Croll’s appliance [4] Moderate to severe ↑ ↓ ↑ ↓
Fixed edgewise appliance Moderate to severe ↑ 5 ↓ ↑ ↓
Surgical uprighting Severe ↑ 5 ↑↑ ↑↑ ↑
 Spring separator Mild to moderate ↓ ✕ ↑ ↓ ↓
Humphrey appliance Moderate to severe ↑ √ ↓ ↑ ↓
Halterman appliance [35] Moderate to severe ↑ √ ↓ ↑ ↓
Croll’s appliance [4] Moderate to severe ↑ √ ↓ ↑ ↓
Dent. Fixed
J. 2023, edgewise
11, 206 appliance Moderate to severe ↑ ✕ ↓ ↑ ↓ 11 of 13
Surgical uprighting Severe ↑ ✕ ↑↑ ↑↑ ↑

Figure 10. Treatment decision flowchart for ectopic first permanent molars.
Figure 10. Treatment decision flowchart for ectopic first permanent molars.

12. Maintenance
12. Maintenance
Relapse is
Relapse is aa common
commonoccurrence
occurrenceafterafterrepositioning
repositioning thethe
first permanent
first permanent molar [7]. [7].
molar A A
simpleway
simple waytotoprevent
preventthis thisisisby
bybanding
bandingthe thesecond
secondprimary
primarymolarmolarusing
usingaamolar
molarbandbandthat
thata has
has a distal
distal extension
extension extended
extended ontoocclusal
onto the the occlusal surface
surface [7].band
[7]. The The band
is notistonot to be
be removed
removed
until afteruntil after the permanent
the permanent molar has molar
beenhas been sufficiently
sufficiently erupted erupted to prevent
to prevent relapse,
relapse, and the
and the patient should be recalled at 6–8-week intervals [7]. On the
patient should be recalled at 6–8-week intervals [7]. On the other hand, in cases whereother hand, in cases
where
the the second
second primary primary
molarmolarmustmust be removed
be removed duedue to extensive
to extensive root
root resorptionororisislost
resorption
lost prematurely, it is advised to plan for space maintenance or closure
prematurely, it is advised to plan for space maintenance or closure with the orthodontist with the ortho- in
dontist in advance
advance [7,42]. [7,42].

13. Conclusions
13. Conclusions
Ectopically erupting
Ectopically erupting permanent
permanentmolars
molarspresent
presentasasananabnormal
abnormal deviation
deviationof of
thethe
nat-
natu-
ural tooth eruption pathway. It is a multifactorial pathological disorder with both
ral tooth eruption pathway. It is a multifactorial pathological disorder with both general general
factors,such
factors, suchas
asfamilial
familial tendencies
tendencies and
and genetics,
genetics, and
and local
local etiological
etiological factors,
factors,such
suchasasab-
abnor-
normal angulation of the permanent molar, maxillary hypoplasia, maxillary
mal angulation of the permanent molar, maxillary hypoplasia, maxillary retrognathism,
permanent molar macrodontia, and delayed permanent molar calcification. The diagnosis
of ectopic permanent molars usually takes place as an incidental finding during clinical
examination and radiographic assessment. Therefore, pediatric dentists and general practi-
tioners need to be aware of the consequences of this condition and how to intervene early
to avoid an irreversible locking of permanent molars that can lead to impaired function,
impaired appearance, pain, infection, resorption to the surrounding tissues and structures,
and, subsequently, the early loss of second primary molars, which would lead to crowding
and multiple orthodontics problems. The treatment of ectopic molars and the time of inter-
vention depend on several factors; however, there is a general agreement that the initiation
of the treatment should start immediately after the diagnosis is obtained. Interproximal
wedging and distal tipping are generally the two main techniques used for management.
Treatment relapse can be prevented by banding the second primary molar until the first
permanent one fully erupts and recalling the patient after 6–8 weeks.
Dent. J. 2023, 11, 206 12 of 13

Author Contributions: Conceptualization, S.A.; methodology, S.A.; resources, S.A., H.A., J.K., L.A.
(Lama Alosail), L.A. (Linah Alali), N.A., and R.A.; data curation, J.K., L.A. (Lama Alosail), L.A. (Linah
Alali), N.A., and R.A.; writing—original draft preparation, J.K., L.A. (Lama Alosail), L.A. (Linah
Alali), N.A., and R.A.; writing—review and editing, S.A. and H.A.; visualization, S.A., J.K., L.A.
(Lama Alosail), and L.A. (Linah Alali); supervision, S.A. and H.A.; project administration, S.A., and
J.K. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: We would like to express our appreciation to Abu-Hussein Muhamad, Bourane
Ambriss, Ik-Hwan Kim, and Min Sun Song for giving us permission to publish Figures 3, 5, 8 and 9.
Conflicts of Interest: The authors declare that they have no known competing financial interests or
personal relationships that could have appeared to influence the work reported in this paper.

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