ORIGINAL ARTICLE

Effects of early loss of permanent first molars

on the development of third molars
İbrahim Yavuz,a Bülent Baydaş,a Ayşegül İkbal,b İlhan Metin Dağsuyu,a and İsmail Ceylanc
Erzurum, Turkey

Introduction: The aim of this study was to evaluate whether early loss of the permanent first molars has an
effect on the developmental stages and eruptive conditions of the third molars. Methods: Panoramic
radiographs and dental casts of 165 adolescent patients (103 boys, 62 girls) with unilateral early loss of a
permanent first molar were used to assess the developmental stages of the third molars. The formation
stages of third molars on the extraction sides were evaluated, and the formative conditions of the
contralateral teeth were used as controls. The Mann-Whitney U test was used to assess sex differences in
formation stages of the third molars. The Kruskal-Wallis analysis of variance (ANOVA) was used to determine
whether there were significant differences in the developmental stages of the third molars between the
various extraction quadrants. In addition, the Wilcoxon signed rank test and the paired t test were used to
compare the differences in the developmental stages and eruptive conditions of the third molars between the
extraction and control sides. Results: The Mann-Whitney U test showed no significant sex differences for the
formation stage of the third molars. Therefore, the data from both sexes were pooled. No statistically
significant differences were found in the developmental stages of the third molars between the various
extraction quadrants in the same jaw and between those in the mandible and maxilla. However, statistically
significant differences were found in developmental stages (P ⬍.001) and eruptive conditions (P ⬍.05) of the
third molars between the extraction and control sides. The development of the third molars on the extraction
side was significantly accelerated compared with the contralateral teeth. Conclusions: Early loss of the
permanent first molars might have an accelerating effect on the development of the third molar on the extraction
side compared with the contralateral teeth. Therefore, emergence of the third molars on the extraction side might
be hastened, and these teeth might erupt earlier than the contralateral teeth. (Am J Orthod Dentofacial
Orthop 2006;130:634-8)

stages of the other teeth.8-10 However, no studies were

T
he teeth most frequently extracted because of
caries and endodontic problems are the first
molars, especially the mandibular first molars,
with high incidences of extraction of these teeth at early
ages in some populations. However, the developmental
and eruptive conditions of the second and third molars
after early loss of the first molars are critical to the
timing of treatment and the selection of an orthodontic
treatment modality.
Many researchers have attempted to determine the
effect of second molar extraction on the eruption or
developmental condition of the third molars.1-7 In
addition, a few studies examined the relationship be-
tween congenitally missing teeth and the formation
From the Department of Orthodontics, Faculty of Dentistry, Atatürk Univer-
sity, Erzurum, Turkey.
a
Assistant professor.
b
Research assistant.
c
Professor.
Reprint requests to: Dr İlhan Metin Dağsuyu, Atatürk Üniversitesi, Diş
Hekimliği Fakültesi, Ortodonti Anabilim Dalı, 25240, Erzurum, Turkey;
e-mail, intraso@yahoo.com.
Submitted, December 2004; revised and accepted, February 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.02.026
634
found examining the effects of early loss of the perma-
nent first molars on the developmental stages of the
third molars.
The effects of extraction of premolars and molars
on the eruption of the third molars were evaluated by
several investigators.11-15 They reported that the loss of
a posterior tooth encourages the eruption of the third
molar and that the closer the extraction site is to the
third molar, the more effect it will have on the devel-
opment of that tooth. They also indicated that, although
extraction of a premolar reduces the frequency of third
molar impaction, the extraction of a molar virtually
eliminates it.11-15
Ronnerman16,17 reported that early loss of the
deciduous molars is followed by early eruption of the
permanent first molars and a tendency to early eruption
of the incisors and the permanent second molars. In
addition, it was found that the permanent second molars
erupted earlier in both jaws after the early loss of the
deciduous second molar.17,18 These findings suggest
that early loss of the deciduous molars might have some
effect on the eruption time of permanent teeth in the
American Journal of Orthodontics and Dentofacial Orthopedics Yavuz et al 635
Volume 130, Number 5

quadrant concerned. However, Garn and Lewis19 no-

ticed that, when a mandibular third molar was missing,
the formation and eruption of premolars and molars on
the same side were delayed.
These findings suggest that congenital absence or
early loss of some deciduous and permanent teeth
might have some effect on the emergence time and
formation stage of the other teeth. Thus, determination
of this relationship, if present, might be useful for
clinicians.
Our aim in this study was to evaluate whether early
loss of a permanent first molar has an effect on the
development of the permanent third molars in the same
quadrant.

MATERIAL AND METHODS

The material consisted of panoramic radiographs
and dental casts of 165 adolescent subjects (103 boys,
62 girls) with early loss of a permanent first molar. The
subjects were selected from a larger sample in the
Department of Orthodontics, Dental Faculty, Atatürk
University, Erzurum, Turkey. The panoramic radio-
graphs were taken with a panoramic radiograph ma-
chine (PC-100, Trophy Radiologic, Vicennes, France)
according to a standardized technique.20 Panoramic
radiographs with good quality images were used in the
study. The subjects’ chronological ages ranged from 13
to 18 years. The mean was 15.35 ⫾ 2.53 years for total
sample. We studied subjects who had unilateral maxil-
lary or mandibular permanent first molars extracted
before the age of 12. The subjects had no permanent
teeth extracted except the first molars and no craniofa-
cial disorders (eg, cleft palate). Subjects with 2 or more
permanent first molars extracted and with congenitally
missing teeth or peg-shaped incisors were not included
in this study. No subject had undergone orthodontic
treatment.
The development of the molars was assessed on the
panoramic radiographs; tooth eruptions were evaluated on
the panoramic radiographs and the dental casts. The
formation stage of the third molar on the side of the
extracted first molar was evaluated. The formative condi-
tion of the third molar on the other side of the same jaw
Fig 1. Dental calcification stages (from Nolla21; re-
was used as the control. The evaluations of the matu-
printed with permission from the American Academy of
ration stages of the third molars on the extraction and Pediatric Dentistry).
control sides were made at different times. The devel-
opmental scores obtained from the third molars on the
extraction sides were compared with the scores of the of the crowns and roots of permanent teeth into 10
contralateral teeth. stages (Fig 1). The formation stages were classified as
The formation stages of the tooth germs were follows: 0, crypt absent; 1, crypt present; 2, initial
evaluated, based on the formative condition of the calcification; 3, crown one third completed; 4, crown
crowns and roots of the third molars according to the two thirds completed; 5, crown almost completed;
method of Nolla.21 This method divides the formation 6, crown completed; 7, root one third completed; 8,
636 Yavuz et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2006

root two thirds completed; 9, root almost completed, Table I. Distributions of chronological age, sex, and
apex open; 10, root apex completed. The system extracted first molars
attributes a developmental score between 1 and 10 Extracted teeth
for each permanent tooth.
The radiographic image of each permanent tooth Mand Mand Max Max
n Age (y) right left right left
was compared with the drawings, and each tooth was
given a developmental score according to the drawing Boys 103 15.65 ⫾ 2.69 18 8 39 38
that it most nearly matched. If the development of the Girls 62 14.82 ⫾ 2.15 8 10 17 27
tooth was between 2 stages, half values or plus scores Total 165 15.35 ⫾ 2.53 26 18 56 65
were used. Mand, Mandibular; Max, maxillary.
In addition, the eruptive conditions of the third
molars on the extraction side were compared with the Table II. Results of Wilcoxon signed rank tests
contralateral teeth. Dental casts were used to determine
whether the third molars had erupted into the oral Developmental Developmental
stage on stage on
cavity. The criterion for the eruption for the third molar extraction side control side
was part of the crown piercing the gingival tissues.12
The distances from the third molars to the occlusal Teeth Mean SD Mean SD Z P
plane in the subjects with unerupted third molars were Third molars 6.76 1.38 6.28 1.49 ⫺9.720 .000*
measured on the panoramic radiographs. The vertical
*P ⬍.001.
distances between the tips of mesiobuccal cusps of the
third molars and occlusal plane were measured in both
extraction and control sides and compared. All assess- The reproducibility of all assessments of dental
ments were made by 1 examiner (I.Y.). developmental stages was found to be good with high
To test the reproducibility of the assessments of dental coefficient values. Kappa values were above 0.85
developmental stages, the same investigator reevaluated (range, 0.85-1.00) for all dental calcification stage
the panoramic radiographs of 20 randomly selected sub- assessments.
jects 2 weeks after the first evaluation. Kappa coefficients The Mann-Whitney U test for sex differences in the
were used to evaluate agreement between the first and formation stages of the third molars showed no signif-
second dental maturity assessments.22 icant differences (Z ⫽ 1.265; P ⫽ .206), and, therefore,
no sex grouping was established. The results of the
Statistical analysis Kruskal-Wallis ANOVA indicated no significant dif-
The Mann-Whitney U test was used to assess sex ferences between the various extraction sides for the
differences in formation stages of the third molars. The developmental stages of the third molars (⌾2 ⫽ .403;
Kruskal-Wallis analysis of variance (ANOVA) was P ⫽ .940).
applied to determine whether there were significant The results of the Wilcoxon signed rank test are
differences in the developmental stages of the third shown in Table II. According to these results, statisti-
molars between the various extraction quadrants (max- cally significant differences were found in the develop-
illary right, maxillary left, mandibular right, and man- mental stages of the third molars between the extraction
dibular left). The Wilcoxon signed rank test was used to and control sides. The development of the third molars
compare the differences in the developmental stages of on the extraction side was significantly accelerated
the third molars between theextraction and control when compared with the contralateral teeth (P ⬍.001).
sides. Data were analyzed with SPSS for Windows In 125 subjects (75.8%), the development of the third
(version 10.0, SPSS, Chicago, Ill). In addition, paired molars on the extraction side was more advanced than
t tests were used to compare the differences in the the contralateral teeth. In 37 subjects (22.4%), the third
eruptive conditions of the third molars between the molars on the extraction and control sides were at the
extraction and control sides in the subjects with une- same developmental stage. In 3 subjects (1.8%), the
rupted third molars. P values below .05 were consid- development of the third molars on the extraction side
ered statistically significant. was delayed (Fig 2).
Of the total group, the third molars had erupted in
RESULTS only 28 subjects (17%). In 6 subjects (21.5%), both
The distributions by chronological age, sex, and third molars on the extraction and control sides had
extracted first molar in the subjects are summarized in erupted completely. In 17 of the remaining 22 subjects
Table I. (77.2%), the third molars on the extraction side had
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 5
Fig 2. Comparison of development of third molars on extraction and control sides.
erupted, but the third molars on the control side had not.
In 5 subjects (22.8%), eruption of the third molars on
the extraction and control sides was almost equal.
The results of paired t test indicated significant
differences between the extraction and control sides for
the eruptive conditions of the third molars in subjects
with unerupted third molars (t ⫽ 2.187; P ⫽ .037). In
6 of the 137 subjects (4.4%) whose third molars had not
erupted, the axial inclinations of the third molars on the
extraction and control sides were significantly different.
In these subjects, therefore, the eruption level of the
third molars was not evaluated. In the remaining 131
subjects (95.6%), the mean distances between the tips
of the mesiobuccal cusps of the third molars and the
occlusal plane were 6.98 mm for the extraction side and
7.75 mm for the control side. In 96 of the 131 subjects
(73.3%), the third molars on the extraction side were
closer to the occlusal plane than the third molars on the
control side. In the other subjects, the distances be-
tween the third molars and the occlusal plane in both
sides were nearly equal.
DISCUSSION
Panoramic radiographs were used to assess dental
maturity because they are ideal for evaluating the
position of teeth and the extent of tooth development,
and estimating the time of emergence of the tooth into
the oral cavity.23
There are a number of standard scales for rating
tooth calcification stages.20,24-27 The method described
by Nolla21 was chosen in this study because it allows
detailed assessment of the formative conditions of the
permanent teeth.
It was essential to include in the study sample subjects
with unilateral extracted teeth to minimize the influence of
Yavuz et al 637
genetic factors. We compared the extraction and nonex-
traction sides in the same subject. Therefore, subjects with
unilateral extracted permanent first molars were included
in this study, and their contralateral teeth were used as the
controls (split-mouth design).
These results give the clinician more information
about developmental conditions of the third molars in
case of early loss of a first molar. Our data indicate that
the development of the third molars on the extraction
side was significantly accelerated when the first molars
were extracted early compared with the contralateral
teeth (P ⬍.001). In most subjects (75.8%), dental
development of the third molars on the extraction side
was more advanced than the contralateral teeth (Fig 2).
In general, development of the third molar crown on the
extraction side was completed, and the furcation region
was formed to allow root formation to start. However,
development of the third molar crown on the control
side was completed or almost completed.
The percentage of erupted third molars in this study
as determined on the dental casts was 17% (28 sub-
jects). The third molars in 6 of the 28 subjects (21.5%)
had erupted completely in both sides, whereas in 17
subjects of the remaining 22 (77.2%), the third molars
on the extraction side had erupted earlier than on the
control side. In those 17 subjects, the cusps of the third
molars on the extraction side had pierced the gingival
tissues, whereas the third molars on the control side had
not. Therefore, it can be said that the eruption of the
third molars in the quadrant concerned is accelerated in
subjects who lost their permanent first molars at an
early age. In the radiographic examination of the
subjects whose third molars had not erupted yet, it was
observed that the third molars on the extraction side
638 Yavuz et al
were significantly closer to the occlusal plane than the
contralateral teeth were (P ⬍.05).
This finding indicates that the third molars on the
extraction side could erupt before the contralateral teeth.
Fanning12 found that, with extractions, emergence
of the third molars was accelerated by 1.35 years in the
maxillary arch and 1.6 years in the mandibular arch.
Similarly, Richardson14 concluded that, because of the
high proportion of extraction patients (94%) in the early
eruption group and because in unilateral extraction pa-
tients only the third molar on the extraction side had
erupted, extraction of a posterior tooth encourages erup-
tion of the third molar. In addition, Moffitt28 investigated
eruption and functions of the maxillary third molars after
extraction of the second molars, and found that extraction
of a second molar hastens the eruption of the third molar
when compared with the norms. He also reported that not
only does the extraction of a maxillary second molar allow
space for the eruption of the third molar, but also earlier
eruption can be expected. These results agree with our
findings; we found that early loss of the permanent first
molars has an accelerating effect on the formation stages
of the third molars on the extraction side when compared
with the contralateral teeth.
The early eruption of the third molars in the same
quadrant, depending on the extraction of a posterior tooth,
has usually been attributed to the increased eruption space
in front of these teeth. However, we found that the third
molars on the extraction side had more advanced devel-
opment than the contralateral teeth. Therefore, early erup-
tion of the third molars on the extraction side is attribut-
able not only to the increased eruption space but also to
the hastened development in these teeth.
CONCLUSIONS
The results of this study suggest that early loss of a
permanent first molar has an accelerating effect on the
development of the third molar on the extraction side,
compared with the contralateral teeth. Therefore, emer-
gence of the third molars on the extraction side in case
of early loss of a posterior tooth might be hastened, and
thus these teeth might erupt earlier than the contralat-
eral teeth. These findings also indicate that the devel-
opmental and eruptive condition of the third molars
after early loss of the first molars should be observed
carefully by an orthodontist or another clinician.
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