European Journal of Orthodontics 1 (1979) 119-124

Published by Churchill Livingstone, London. © European Orthodontic Society, 1979

A consideration of the advantages of

second molar extractions in orthodontics
R. Lehman
University of Amsterdam, The Netherlands

Summary. Second molar extractions offer some advantages in the treatment of certain types
of malocclusion, including reduction of the appliance complexity and treatment duration. The
indications and the contra indications for second molar extractions are discussed and some
treated cases are shown.

The distal part of the dental arch, especially is therefore essential in orthodontic treatment

Downloaded from by guest on October 24, 2015

the third molar area, is sometimes neglected planning.
in orthodontic treatment planning, resulting Turley and Ricketts (1976), using com-
in problems many years after the end of puterized radiographic material, have de-
active orthodontic treatment. veloped a method for assessing the prognosis
Mandibular third molar impaction is a for third molar eruption at the age of 8 to 10.
major problem in modern dentistry, its They differentiate between third molars that
incidence ranging from 9.5 % (Hellman, 1938) are impacted and unerupted, partly erupted
to 25% (Ricketts, 1972) in different popula- without occlusal contact, and fully erupted in
tions. The incidence is higher among ortho- good occlusal contact. Richardson (1977),
dontic patients and Ricketts (1972) stated that however, claims that accurate prediction of
more than 50% of orthodontic patients third molar impaction from radiographic
require extraction of lower third molars. measurements at the age of 10 is impossible;
Although many impacted teeth remain differences in the size and shape of the
symptomless they do constitute a potential mandible at the age of 10 in those groups who
source of trouble and may lead to a variety of develop impacted or erupted third molars are
pathological conditions including crowding very small, but do tend to become more
in the lower arch, bone, gingival and perio- obvious in later years as a result of individual
dontal inflammation and follicular cysts. differentiation in the degree and direction of
Third molar removal may involve painful growth. Schulhof (1976), in contrast, states
operative procedures in the late teens. that computerized methods are capable of
Sillman (1964) showed that there is only predicting space available to an accuracy of
a minimal increase in the total length of the 2.8 mm at this age. While variance of 2.8 mm
alveolar process during the period from 12 to may be enough to transfer a patient from the
20 years of age—the period during which the impacted group to the marginal group, or
second and third molars, which are relatively from the marginal group to the good occlusion
large teeth, normally erupt. Bjork (1956) has group, it will not be sufficient to change a
shown that 90 % of third molar impactions prognosis from the .impacted to the good
are caused by arch length deficiency. Con- occlusion group.
sideration of the second and third molar area Faubian (1968) demonstrated that the
120 SECOND MOLAR EXTRACTION IN ORTHODONTICS

prevalence of third molar impacted is reduced,

but not eliminated, in cases treated by
extraction of premolars. Richardson (1974)
found that extraction of a molar almost
eliminates the occurrence of third molar
impaction. The extraction of second molars
occasionally offers some additional advan-
tages.

Advantages of second molar extraction

Reduction of treatment time and complexity

Extraction of first or second premolars in the

treatment of minor arch length deficiency in
the anterior part of one or both dental arches
almost always necessitates fully banded
appliances to close the extraction spaces and
to permit root paralleling. Active treatment
may take 1 | to 2 years.Jf such a case is

Downloaded from by guest on October 24, 2015

treated by second molar extraction and GoM
simple headgear or a lip bumper, treatment
time is seldom more than one year. NaPo
Figure 1 Tracing, showing changes in the lower arch
after second molar extraction and headgear therapy
Increased stability of the treated occlusion on upper first molars. Solid outline before treatment.
Dotted outline after treatment.
By treating minor arch length deficiencies of
the anterior part of the dental arch by
extraction of distally placed teeth, the teeth
are only moved over small distances and the the lower anterior teeth, with the incisal edge
risk of relapse by reopening of extraction of the lower incisors reaching the facial plane
spaces is reduced. Furthermore, subsequent and the lower incisor inclination approaching
influence of the third molars on lower arch 90° in relation to the ML line. These factors
length is reduced by extraction of second are all considered to favour stability of the
molars. The tracing in Fig. 1 shows the end result.
changes in the lower arch following second
molar extraction and headgear therapy
applied to the upper first molars. Uprighting Prevention of flaring-out of the second
and distalizing of the lower first molars molars after headgear treatment
occurs because of inter-occlusal forces. This
uprighting, with the long axis of the first molar Buccal eruption of the second molars is
becoming almost perpendicular to the occlusal frequently seen after headgear treatment in
plane, leads to the resultant of occlusal forces the upper arch (Fig. 3) and this can only be
crossing the centre of resistance and contri- controlled by banding the second molars
butes to stability. and adjusting their position by means of
The combination of uprighting and buccal root torque. This necessitates fully
distalizing may provide sufficient space in the banded therapy but can be avoided by second
lower arch (Fig. 2) resulting in uprighting of molar extraction.
SECOND MOLAR EXTRACTION IN ORTHODONTICS 12-1

Preconditions for second molar extraction The developing third molars, particularly in
the lower jaw, must be favourably inclined.
Among the prerequisites for optimal treatment In a successful result the third molars
results with second molar extraction are: should be fully erupted in the dental arch and
Existing or anticipated arch length deficiency should be in good occlusion with their
in the distal part of the dental arch. antagonists with no balancing contacts during
All third molars present and of normal size articulation; there should be a good contact
and shape. relationship with the first molar at the normal
No congenital absence or loss of teeth else- height and the long axis of the third molar
where in the dental arch. should not diverge more than 5° from the
Optimal timing of the extractions. long axis of the first molar. In achieving these

Downloaded from by guest on October 24, 2015

122 SECOND MOLAR EXTRACTION IN ORTHODONTICS

Downloaded from by guest on October 24, 2015

Figure 2 Casts of patient treated with second molar extraction and headgear therapy on upper first molars. On the
left the pre-treatment condition. Note the crowding in the upper anterior arch and the buccal segments of
the lower arch. On the right the situation at the end of treatment. Note the decrease of sagittal overjet and
vertical overbite.

developmental stage in which the crowns of

the third molars are fully developed but before
any radiographic signs of root formation are
evident. The long axis of the developing
mandibular third molar should make an
angle of 15-30° with the long axis of the first
molar (Fig. 4).

Indications and conrra-indications

Figure 3 Buccal eruption of second molar after There are three types of malocclusion in
headgear therapy on upper first molars. which second molar extraction may be
indicated:
criteria the extraction timing and favourable Skeletal Class I malocclusion combined with
inclination of the third molars are particu- arch length deficiency in the distal part of
larly important. The best results are obtained the dental arch.
when the second molars are removed at the Skeletal Class I malocclusion combined with
SECOND MOLAR EXTRACTION EN ORTHODONTICS 123

mild crowding in the anterior part of one or advantage of the orthopaedic effect of the
both dental arches. treatment and to prevent lingual version of the
Skeletal Class II malocclusion with mild upper front teeth and a slight Class II rela-
crowding in the lower dental arch. tionship in the buccal teeth at the end of
It is important that headgear treatment treatment.
in the skeletal Class II cases is instituted A contra-indication is anticipated de-
during the puberal growth spurt to take velopment of an abnormal vertical relation.

Downloaded from by guest on October 24, 2015

Figure 4(a) Radiograph of patient, shortly after second molar extraction, (b) Radiograph of same patient,
four years after second molar removal. Although signs of root formation of third molars were visible at the
time of extraction of second molars, the third molar on the right side managed to achieve a good position, in
contrast to the third molar on the left side.
124 SECOND MOLAR EXTRACTION IN ORTHODONTICS

The consequence of second molar extraction Mandibular growth and third molar
in a developing deep bite is shown on the impaction. Transactions of the European
X-rays in Fig. 5. To create a normal vertical Orthodontic Society, 164.
relationship in this case a degree of sweep had Faubian, B. H. (1968). Effect of extraction of
to be built into the archwires during treatment premolars on eruption of mandibular third
and the unfavourable result of this is clearly molars. Journal of the American Dental
seen in the distal inclination of the lower first Association, 76: 316.
molars. The centre of resistance of the tooth Hellman, M. (1938). Some aspects of wisdom
is unfavourably located relative to the teeth and their impactions. Archives of
occlusal forces and the stability of the result Clinical Oral Pathology, 2: 125.
is therefore questionable. Had the second
Richardson, M. E. (1977). The etiology and
molars been incorporated in the treatment
prediction of mandibular third molar
procedure this would have given an enormous
impaction. Angle Orthodontist, 3: 165-172.
anchorage potential and a fraction of the
sweep would have resulted in the same vertical Richardson, Margaret E. (1974). Some aspects
relations in the anterior part of the dental of lower third molar eruption. Angle
arch with a much more favourable tooth Orthodontist, 44: 141.
inclination in the molar region. Ricketts, R. M. (1972). The principle of arcial
growth of the mandible. Angle Orthodontist,
42: 368.
Ricketts, R. M., Turley, P., Shackonas, S.

Downloaded from by guest on October 24, 2015

(1976). Third molar enncleation: diagnosis
and technique. Journal of the Californian
Dental Association, 4:4: 52-56.
Schulhof, R. J. and Bagha, L. (1975). A
statistical evaluation of the Ricketts and
Johnston growth-forecasting methods,
American Journal of Orthodontics, 67: 3.
Schulhof, F. R. (1976). Molar and ortho-
dontic diagnosis. Journal of Clinical Ortho-
dontics, 10:272-281.
Sillman, J. H. (1964). Dimensional changes of
the dental arches: Longitudinal study from
birth to 25 years. American Journal of
Figure 5 The consequence of a second molar Orthodontics, 50, 11: 824-842.
extraction in a developing deep bite.
Wilson, H. E. (1974). Long term observation
on the extraction of second permanent
References
molars. Transactions of the European
Bjork, A., Jensen, E. and Palling, M. (1956). Orthodontic Society, 215-221.