ACTA ODONTOLOGICA SCANDINAVICA

2024, VOL. 83, 582–587

https://doi.org/10.2340/aos.v83.42076

RESEARCH ARTICLE

Assessing position changes of impacted third molars in treatment of class II

malocclusion with premolars extraction
Hatice Gokalpa and Murat Kaan Erdemb
a
Department of Orthodontics, Faculty of Dentistry, Ankara University, Ankara, Turkey; bDepartment of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Lokman Hekim University, Ankara, Turkey

ABSTRACT ARTICLE HISTORY

Introduction: Third molars (M3) remaining impacted in Class II malocclusion characterised with sagittal Received 17 August 2024
mandibular deficiency is a high probability. The null hypothesis of this study is that mesioangular M3s Accepted 23 September
changes position through the eruption way in Class II malocclusion treatment requiring moderate anchor- 2024
age with four first premolars extraction. The aim of this study is to reconsider the decision to surgically
KEYWORDS
extract impacted third molars in four premolars extraction treatment of Class II malocclusion. Class II malocclusion;
Material and Methods: The materials consisted of the pre-treatment and post-treatment lateral cepha- moderate anchorage;
lograms and orthopantomographs of 30 individuals with skeletal and dental Class II malocclusion with a orthodontic therapy with
mean chronological age of 13.48 years, who were treated by the same clinician (H.G.) with four first pre- extraction; third molar
molar extractions via the straight wire technique at the Ankara University Faculty of Dentistry Department impaction
of Orthodontics, Ankara, Turkey. The sagittal position of the upper and lower incisors and molars, M3 posi-
tion and M3 space were evaluated with the paired-t test; the relationship between the sagittal position of
the upper and lower incisors and molars and the change in M3 position were evaluated with correlation
analysis.
Results: The study found the retroclination and mesial movement of the upper incisors and molars, and an
increase in the M3 space by the fixed orthodontic treatment. An insignificant steepening of both the upper
right M3 position and the lower right M3 position was found. A statistically significant increase in the lower
right and left side M3 spaces was found. Positive correlations between lower right M3 angulation and the
sagittal position of the lower incisors and first molars were found.
Conclusion: Improvement in the mesioangulation of the M3s and an increase in the M3 space were
achieved in this study. Based on the findings, it is useful to review the decision for prophylactic surgical
extraction of the M3s before orthodontic treatment in such cases, taking into account the risks of postop-
erative complications.

Introduction
both the number and size of individual teeth and jaw size
Tooth impaction is a common occurrence, affecting 0.8% – 3.6% throughout evolution. Initially, primates had more teeth, but
of the general population, mainly because of space constraints over time, the third premolars and fourth molars disappeared in
in the dental arches or other conditions that hinder eruption. mammals. Presently, it is not uncommon for M3s, second
These are influenced by systemic, local, genetic, and racial fac- premolars, and lateral incisors to sometimes fail to form [8].
tors [1, 2]. The teeth most frequently impacted include maxillary Orthodontic treatment often requires the extraction of first
and mandibular third molars, maxillary canines, mandibular pre- premolars to achieve desired treatment outcomes. However, in
molars, and maxillary central incisors [3, 4]. treatments characterised by a forward mandibular growth
Mandibular third molar (M3) impaction was initially attributed pattern, the length of the dental arch may decrease, leading to
to inadequate space between the second molars (M2) and the the impaction of M3s because of factors such as ramus anterior
ascending ramus. Later studies identified additional contributing remodelling, late mandibular growth spurt, and retrusion of the
factors, such as mandibular growth deficiency, vertical condylar lower incisors [1, 6, 8–12]. In orthodontic treatment plans,
growth, and the backward eruption path of the dentition [5, 6]. regardless of whether extractions are involved, the common
In recent times, changes in eating habits that affect chewing approach is to prophylactically extract asymptomatic M3s,
patterns, coupled with insufficient jaw lengthening, have independent of craniofacial growth characteristics. However,
resulted in an increased prevalence of M3 impaction, ranging the margin of error in estimating the risk of impaction is 40%
from 16.7% to 68.6% [7]. Fossil records indicate a reduction in [13, 14]. This substantial uncertainty is particularly concerning

CONTACT Murat Kaan Erdem [email protected] Dentistry, Department of Oral and Maxillofacial Surgery, Lokman Hekim University, Sogutozu
Mahallesi, Cankaya, Ankara, Turkey
© 2024 The Author(s). Published by MJS Publishing on behalf of Acta Odontologica Scandinavica Society. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to
remix, transform, and build upon the material, with the condition of proper attribution to the original work.
583 H. GOKALP AND M.K. ERDEM

given that surgically extracting asymptomatic M3s in adolescents at the Ankara University Faculty of Dentistry, Department of
can lead to long-lasting neurological and psychological Orthodontics. All premolars were extracted by the same sur-
complications [15, 16]. Therefore, it is crucial to evaluate the geon (M.K.E.). A power analysis determined that a sample size of
prognosis of M3 eruption alongside anchorage requirements, 30 was adequate. All radiographs were taken by the same tech-
craniofacial growth patterns, M3 angulation, and M3 spacing to nician using a Planmeca ProMax Device, set at 66 kV and 9 mA,
minimise surgical complications. with the patients’ mouths closed. The mean treatment duration
In cases of Class II malocclusion requiring maximum was 2.7 years (range: 1.90–4.50 years).
anchorage, distal molar movement may increase the risk of M3 The average chronological age of the individuals at the
impaction because of the influence of craniofacial growth beginning of treatment was 13.48 years (range: 11.80–19.30
direction on the remodelling of the ascending ramus [6]. years). Inclusion criteria were:
Numerous studies on M3 impaction in the treatment of Class
I, II, and III malocclusions, with or without extraction and during 1. Maxillary and mandibular arch length discrepancy with
or after the growth period, are retrospective. These studies often moderate anchorage requirements: −7.45 mm and −5.19
fail to prioritise the relationship between anchorage requirements mm, respectively; Class II molar and canine relationship;
and craniofacial growth characteristics in M3 impaction. overjet: 4.90 mm (range: 1.00–15.00 mm); overbite: 2.15
However, the craniofacial growth pattern significantly influences mm (range: −4.0 to 5.0 mm).
tooth alignment within the alveolus. 2. SNA, 85º; SNB, 79º; ANB, 6º.
The null hypothesis of this study is that mesioangular M3s 3. GoGn-SN, 35.4º.
undergo positional changes during the eruption process in the 4. All third molars present and in a mesioangular position on
course of treating Class II malocclusion, particularly in cases that OPG, according to Archer’s and Winter’s classifications
require moderate anchorage and involve the extraction of all ([17, 18]; Figures 1 and 2).
four first premolars. The primary aim of this study is to critically
reevaluate the decision-making process regarding the surgical At the end of orthodontic treatment, occlusion was achieved in
extraction of impacted third molars within the framework of accordance with Andrews’ normal occlusion criteria [19]. On
Class II malocclusion treatments that include the extraction of OPG, all M3s were present, and at least one-third of root forma-
four premolars. tion was completed. Temporary intraoral anchorage systems or
extraoral anchorage applications were not used during fixed
orthodontic treatment. Changes in M3 space and angulation
Materials and methods were evaluated on lateral cephalograms and OPGs at the end of
the treatment (Figures 3 and 4).
Sample design
This study was conducted on the lateral cephalograms and
Study design
orthopantomograms (OPG) of 30 patients with skeletal and
dental Class II malocclusion requiring moderate anchorage. To evaluate sagittal changes in the positions of incisors and
These patients were treated by the same orthodontist (H.G.) molars and M3 spaces in both dental arches, a Cartesian coordi-
using the straight wire technique with four premolar extractions nate system was used. The X-axis was created between the

Figure 1. Archer’s classification of upper third molars according to their inclination to the long axis of the upper second molar. (1) mesioangular, (2) distoan-
gular, (3) vertical, (4) horizontal, (5) buccoangular, (6) linguoangular, (7) inverted.
 ACTA ODONTOLOGICA SCANDINAVICA 584

Figure 2. Winter’s classification (19): Third molars are classified according to their inclination to the long axis of the second molar. (1) vertical angulation, (2)
horizontal angulation, (3) distoangular angulation, (4) mesioangular angulation, (5) transversal angulation, (6) inverse angulation.

anterior nasal spine (ANS) and posterior nasal spine (PNS) points, Sagittal changes in the positions of the upper incisors, molars,
and was used for both upper and lower dental arches. The Y-axis and M3 spaces were measured relative to the Y-axis. The Y-axis for
for the maxilla was constructed from the PNS point to the X-axis. the mandible was constructed from the point where the anterior
border of the ascending ramus joins the end of the corpus man-
dible to the X-axis. Sagittal changes in the positions of the lower
incisors, molars, and M3 spaces were measured relative to the
Y-axis. M3 spaces for upper and lower dental arches were meas-
ured as the distances between the U6d and Y-axis (maxilla), and
L6d and Y-axis (mandible). Reference landmarks and lines for
measurement on lateral cephalograms are presented in Figure 3.
Positional changes of the M3s were evaluated on OPG. Points and
reference lines used on OPG are shown in Figure 4.

Statistical method
SPSS (Statistical Package for the Social Sciences) 26 was used for
data analysis. The intraclass correlation coefficient was used to
measure reliability. Because of the limited data for comparing
the beginning and end of the treatment using lateral cephalo-
gram and OPG measurements (N = 30), the nonparametric
Wilcoxon signed-rank test was used as an alternative to the
dependent group t-test for comparing two different measure-
ments within a single group [20]. The nonparametric Brown cor-
relation method was used instead of the Pearson correlation
method to assess measurement differences between the begin-
ning (T0) and end (T1) of treatment. The correlation coefficient
Figure 3. Points and reference lines for measurement of Lateral cephalograms. (r) was considered low if below 0.40, medium if between 0.40
Points. 1. ANS, anterior nasal spine; 2. PNS, posterior nasal spine; 3. Ricketts Xi and 0.70, and high if equal to or greater than 0.70 [21]. A signifi-
point 4. Ui, upper incisor edge, 5. U6d, upper first molar distal edge, 6. Li, lower cance level of p < 0.05 was used for statistical analyses.
incisor edge, 7. L6d, lower first molar distal edge. Reference Lines: 1. FH, Frank-
Measurements were conducted twice with a 20-day interval
fort horizontal line; 2. X-axis is made between the ANS and PNS points. 3. Y-axis
to determine the repeatability of landmark identification and
for maxilla is perpendicular line from PNS point to x-axis. 4. Y-axis for mandible
is perpendicular line from Xi point to x-axis. Measurements: 1. Ui- y-axismax, 2. measurement techniques. All angular and linear variables
U6d- y-axismax, 3. L6d- y-axismax 4. L6d- y-axisman. 5. M3 space for maxilla: distance exhibited a coefficient of intra-rater reliability between 0.82 and
between U6d and y-axismax. 6. Distance between L6d and y-axisman. 1.00, indicating negligible variation.
585 H. GOKALP AND M.K. ERDEM

Figure 4. Points and reference lines for measurement of OPG. Points: 1. UM3t, Upper third molar occlusal surface midpoint 2. U6mt, Upper first molar mesial
tubercule top 3. UM3c Upper first molar midpoint of apex. 4. U5t, upper second premolar tubercule top, 5. LM3t, lower third molar occlusal surface midpoint
6. L6mt, lower first molar mesial tubercule top 8. LM3c lower first molar midpoint of apex. 9. L5t, lower second premolar tubercule top. Reference Lines: 1.
OPmax, maxillary occlusal plan which is constracted between U5t and U6mt. 2. OPman, mandibular occlusal plan which constracted between L5t and L6mt, 3.
Long axis of UM3, line between UM3c and UM3t. 4. Long axis of LM3, line between LM3c and LM3t. Measurements: 1. UM3 angulation, angle between OP max
and long axis of UM3. 2. LM3 angulation, angle between OP man and long axis of LM3.

Sagittal position changes of the incisors and molars, M3 A statistically significant positive correlation was found
spaces, and mesioangular M3s were analysed using a paired-t between treatment and changes in the positions of U6 and L6
test at T1. The relationship between changes in the positions of (p < 0.05, Table 3). Additionally, a statistically significant positive
incisors/first molars and changes in M3 positions and M3 spaces correlation was found between the lower right M3 position and
were tested using correlation analysis. the positions of the lower incisors and lower first molars (p < 0.01,
Table 3).

Results
Discussion
At the end of orthodontic treatment, a statistically significant
retraction of the upper incisors and mesialization of the molars This study examined the changes in the required space for
was observed (p < 0.01), along with a significant increase in the the eruption of mesioangular M3s and their angulation
upper M3 space (p < 0.01, Table 1). Although there was no during fixed orthodontic treatment involving four premo-
change in the lower incisor position, a statistically significant lar extractions and moderate anchorage requirements.
mesialization of the lower molars and an increase in the lower While many studies have addressed this topic, controversies
M3 space were found (p < 0.01, Table 1). remain regarding craniofacial growth patterns, impaction
A statistically significant decrease in the right lower M3 detection methods, and orthodontic treatment planning. This
angulation was detected at the end of the treatment (p < 0.05, study found that fixed orthodontic treatment with four premo-
Table 2), while no significant changes were observed in the lar extractions, requiring moderate anchorage, led to upper inci-
positions of other M3s. sor retraction, molar mesialization, an increase in the space

Table 1. Changes of upper and lower incisors and first molars in addition to
M3 spaces in both arches at T0 and T1.
n = 30 Before Treatment (T0) After Treatment (T1) p Table 2. Sagittal position changes of M3s on OPG by orthodontic treatment.
X ± Sx X ± Sx Before Treatment After treatment p
U1 position (mm) 51.52 ± 4.22 48.68 ± 4.17 ** (T0) (T1)
U6 position (mm) 22.42 ± 4.12 24.95 ± 3.42 ** x ± S× x ± S×
M3 max space (mm) 10.13 ± 3.18 12.65 ± 3. 55 ** Long axis of URM3/OPmax 63.04 ± 20.49 65.54 ± 11.42 Ns
L1 position (mm) 50.68 ± 3.47 50.25 ± 4.61 Ns Long axis of LRM3/OPman 146.72 ± 18.32 141.10 ± 21.14 *
L6 position (mm) 27.37 ± 3.15 30.23 ± 3.79 ** Long axis of ULM3/OPmax 61.52 ± 18.31 64.48 ± 15.10 Ns
M3 man space (mm) 13.20 ± 3.17 16.06 ± 6. 53 ** Long axis of LLM3/OPman 134.88 ± 19.05 131.52 ± 21.11 Ns
Significance level: Ns: Not significant; **p < 0.01. Significance level: Ns: Not significant; *p < 0.05, **p < 0.01.
 ACTA ODONTOLOGICA SCANDINAVICA 586

Table 3. Correlations analysis results between changes of sagittal Declarations

positions of the upper and lower incisors and molars and M3s position
changes. Conflict of Interests: The authors declare no conflict of interest
U6 L1 L6 or financial interest.
L6 0.417* Ns Ns Ethical Approval: Ethical approval for this study was
Long axis of LRM3/OPman Ns 0.480** 0.484** obtained from the Ankara University Faculty of Dentistry Clinical
Significance level: *r0.05 = 0.374, **r0.01 = 0.479. Research Ethics Committee and in accordance with the 1964
Declaration of Helsinki and its subsequent changes or similar
ethical standards.
necessary for M3 eruption in both the upper and lower dental Patient Consent: Written informed consent was obtained
arches, and an improvement in the mesioangular M3 position. from all individual participants included in the study.
Anchorage requirements play a critical role in tooth All authors have viewed and agreed to the submission.
movement during orthodontic treatments involving extractions.
Different anchorage systems yield varying results in tooth
positioning. In this study, patients were treated only with fixed Author Contributions
orthodontic treatment, without the use of intraoral or extraoral
Conceptualisation: H.G. and M.K.E. Methodology: H.G. and
anchorage systems. Increased anchorage requirements in the
M.K.E. Software: H.G. and M.K.E. Validation: H.G. and M.K.E.
orthodontic treatment of Class II malocclusion, necessary for
Formal analysis: H.G. and M.K.E. Investigation: H.G. and M.K.E.
retracting the upper incisors and molars, may contribute to M3
Resources: H.G. Data curation: H.G. and M.K.E. Writing – Original
impaction.
draft: H.G. and M.K.E. Writing – Review & Editing: H.G. and M.K.E.
Orthopantomograms were utilised to assess M3 angulation
Visualisation: H.G. and M.K.E. Supervision: H.G. Project adminis-
in this study. Although cone-beam computed tomography
tration: H.G. and M.K.E. Funding acquisition: No funding
(CBCT) has gained popularity, OPGs remain a standard practice
because of their routine use and lower radiation doses in
orthodontics [22, 23]. Funding
Various factors influence the space available for M3 eruption.
Richardson noted that mesial molar movement can partially No funding was obtained for this study.
increase the space for M3 eruption [1]. Brash and Scott observed
that anterior dentition movement contributes to creating space
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