J Oral Maxillofac Surg

68:990-995, 2010

Frequency of Agenesis, Impaction,

Angulation, and Related Pathologic
Changes of Third Molar Teeth in
Orthodontic Patients
Mevlut Celikoglu, DDS,* Ozkan Miloglu, DDS, PhD,†
and Fatih Kazanci, DDS‡

Purpose: The objectives of the present study were to investigate the frequency of impaction, agenesis,
angular position, and related pathologic changes of third molar teeth in a group of orthodontic patients.
Materials and Methods: Our sample included the panoramic radiographs of 351 orthodontic patients
aged 20 to 26 years (mean 22.8). The descriptive characteristics of agenesis, impaction, angular position,
and pathologic changes of third molars were recorded. The ␹2 test was used for analysis.
Results: The proportion of third molar agenesis was 17.3% with no statistically significant gender
differences (18.4% for women and 15.8% for men). The frequency of impacted third molars (ITMs) was
35.9% (24.2% in men and 45.0% in women; P ⬍ .05). The frequency of maxillary ITMs was 43.2% (192
of 444 teeth), and the frequency of mandibular ITMs was 56.8% (252 of 444 teeth). The position observed
most often was mesioangular inclination, with a frequency of 50.0%. Only 10.4% of the ITM teeth were
affected by any pathologic changes, and most of these changes were associated with the horizontal
position.
Conclusions: The present results showed that agenesis accounted for 17.3% and impaction for 35.9%
of the pathologic features in this group of Turkish orthodontic patients aged 20 to 26 years of age.
Mesioangular inclination was seen in 50.0%, and a small proportion (10.4%) had pathologic changes of
the ITMs.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:990-995, 2010

The third molar is characterized by the variability in
the time of its formation owing to the widely varying
crown and root morphology and by its varying pres-
ence or absence in the mouth cavity. In addition,
third molars are the most frequently impacted teeth
because they are the last teeth to erupt. Impacted
third molars (ITMs) are a major problem in modern
dentistry and the decision of whether to remove an
ITM is probably one of the most frequent treatment
Received from the Faculty of Dentistry, Ataturk University, Er-
zurum, Turkey.
*Research Assistant, Department of Orthodontics.
†Research Assistant, Department of Oral Diagnosis and Radio-
logy.
‡Research Assistant, Department of Orthodontics.
Address correspondence and reprint requests to Dr Celikoglu:
Department of Orthodontics, Ataturk University Faculty of Dentistry,
Erzurum 25240 Turkey; e-mail: mevlutcelikoglu@hotmail.com
© 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6805-0007$36.00/0
doi:10.1016/j.joms.2009.07.063
decisions faced by dentists.1-3 Although some ITMs
are asymptomatic, others can cause complications
such as pain, infection, cysts, tumor, jaw fractures, or
malposition of the mandibular anterior teeth. They
can also cause caries and root resorption of the adja-
cent teeth.4,5
To date, no information has been documented from
the Turkish orthodontic population regarding the
prevalence or agenesis of ITMs or the time and se-
quence of their eruption. The aims of the present
study were to investigate the frequency of agenesis,
impaction, angular position, and related pathologic
changes of third molar teeth in a group of orthodontic
patients referred to the Department of Orthodontics,
Ataturk University Faculty of Dentistry in Turkey.
Materials and Methods
Our sample included the panoramic radiographs of
368 patients aged 20 to 26 years (mean 22.8 ⫾ 3.1),
who were treated by graduate students at the Depart-
ment of Orthodontics, University of Ataturk. The pa-

990
CELIKOGLU, MILOGLU, AND KAZANCI
tients with congenital deformities, such as cleft pal-
ate, or panoramic radiographs of poor quality were
excluded from the present study. The subjects were
also evaluated to confirm that they had not previously
undergone surgical removal or extraction of one or
more third molars. Of the 368 patients, 17 were ex-
cluded. Thus, 351 patients (198 women and 153 men)
were included in the present study. All radiographs
were performed by an x-ray technician who had a min-
imum working experience of 5 years as of 1996 using an
orthopantomography device (Proline CC2002, 60 to 80
kVp, 8 to 10 mA, 12.8-second exposure time, Planmeca,
Helsinki, Finland), with a magnification factor of 1.2.
Approval from the ethics committee was not required
for this retrospective study.
The diagnosis and inclusion criteria for agenesis of
the third molars were done using the description
presented by Endo et al.6 The teeth were classified as
developmentally missing when no evidence was
found in the records that they had been extracted and
when no sign of mineralization of the tooth crown
was found on the panoramic radiographs. Impaction
was defined as incomplete eruption of the third molar
owing to its inclined position relative to the second
molar or the ascending ramus or vertical impaction
owing to a lack of space.7
The third molar angulation was measured with ref-
erence to the anterior angle between the occlusal
plane of the first and second premolars, and a line was
FIGURE 1. A-D, Pathologic changes associated with ITMs.
Celikoglu, Miloglu, and Kazanci. Agenesis, Impaction, Angulation of Third Molar Teeth. J Oral Maxillofac Surg 2010.
991
drawn through the occlusal surface of the third molar.
The method of Shiller8 was used to measure the
angulation of the third molars. The data obtained from
the panoramic radiographs were classified as follows:
vertical, 0° to 10°; mesioangular or distoangular, 11°
to 70°; and horizontal, ⱖ71°. A group of cases with
inverted or buccolingual angulation were classified as
inverted.
The pathologic conditions determined from the
panoramic radiographs were as follows3,9: 1) distal
root resorption of an adjacent molar; 2) distal cervical
caries on an adjacent molar; 3) decreased alveolar
bone of an adjacent molar; and 4) coronal radiolu-
cency in the ITM. In the published data, to detect the
pathologically widened pericoronal space, a cutoff
point of 2.5 mm for panoramic radiographs has been
accepted (Fig 1).3 It was calculated that a width of 2
mm would be 2.5 mm because of the area enlarge-
ment coefficient of 1.2 in the panoramic equipment
used. Therefore, in the present study, the lesions in
which the widest area of the distal aspect of the ITMs
was ⬎2.5 mm were considered pathologic condi-
tions.
The radiographs were examined by 2 investigators
(a dentomaxillofacial radiologist and an orthodontist).
To check for the diagnostic reproducibility of the
inter-reliability of the 2 investigators, 10% of the ra-
diographs assigned by them were randomly examined
each day for 3 consecutive days. An examination of
992 AGENESIS, IMPACTION, ANGULATION OF THIRD MOLAR TEETH

Table 1. DISTRIBUTION OF PATIENTS WITH THIRD MOLAR AGENESIS BETWEEN GENDERS

Third Molar Agenesis Women Men Total ␹2 P Value

Teeth (n) 1.61 .20

Third molar agenesis 146 (18.4) 97 (15.8) 243 (17.3)
Expected No. of third molars in patients 792 (56.4) 612 (43.6) 1,404 (100.0)
Patients (n)
0 molars absent 122 (61.6) 101 (66.0) 223 (63.5) 0.72
1 molar absent 37 (18.7) 14 (9.2) 51 (14.5) 6.32
2 molars absent 20 (10.1) 31 (20.3) 51 (14.5) 7.17
3 molars absent 3 (1.5) 4 (2.6) 7 (2.0) 0.54
All 4 molars absent 16 (8.1) 3 (2.0) 19 (5.4) 6.31
Data in parentheses are percentages.
Celikoglu, Miloglu, and Kazanci. Agenesis, Impaction, Angulation of Third Molar Teeth. J Oral Maxillofac Surg 2010.

the results using the Wilcoxon matched-pairs signed
rank test showed no statistically significant differ-
ences between the 2 observers, indicating diagnostic
reproducibility. In addition, 10% of the remaining
radiographs were selected randomly and re-evaluated
twice by the same examiner 6 weeks after the first
evaluation. The intraexaminer reproducibility was
96% and 90% for the 2 investigators.
The variables were analyzed using the Statistical
Package for Social Sciences, version 12.0 (SPSS, Chi-
cago, IL), and the Pearson ␹2 test was used to deter-
mine potential differences in the distribution of anom-
alies when stratified by gender. A P value of ⬍ .05 was
considered statistically significant.
Results
The frequency of third molar agenesis was 17.3%
(243 teeth missing of 1,404). The frequency of third
molar agenesis for the women (18.4%; 146 teeth of
792) was greater than that for the men (15.8%; 97
teeth of 612). This difference was not statistically
significant. Of the 351 patients, 63.5% had all 4 mo-
lars, 14.5% had 3 molars, 14.5% had 2 molars, 2.0%
had 1 molar, and 5.4% had agenesis of all 4 third
molars (Table 1).
Of those with one or more third molars present, the
percentage of patients with an ITM was 35.9% (24.2%
of men and 45.0% of women). This difference be-
tween women and men was statistically significant
(P ⬍ .05; Table 2).
The frequency of an ITM was 38.2% (20.9% in men
and 52.1% in women). In addition, the frequency of a
maxillary ITM was 43.2% (192 of 444 teeth) and of a
mandibular ITM was 56.8% (252 of 444 teeth). Max-
illary ITMs had a greater frequency in the vertical
position (58.9%), followed by a distoangular (25.0%),
mesioangular inclination (14.1%), and horizontal
(1.0%) position. The mandibular ITM had the greater
frequency of a mesioangular inclination (77.4%). The
horizontal position was the second most frequent,
representing 13.5% in the mandible followed by ver-
tical (8.7%) and distoangular (1.2%) ITMs (Table 3).
Pathologic changes were observed in 14 (7.3%) of
the 192 maxillary ITMs and 32 (12.7%) of the 252
mandibular ITMs. The most frequently observed
pathologic change in the maxilla was root resorption
of an adjacent molar (4.2%; 8 of 192 teeth). In the
mandible, 13 (5.2%) of 252 mandibular ITMs had
decreased the alveolar bone of an adjacent molar,
followed by 9 (3.6%) that had resulted in distal root
resorption of an adjacent molar and 7 (2.8%) that had
caused distal cervical caries on an adjacent molar.
When all the results were considered together, only
10.4% of all ITMs were affected by any of the patho-
logic changes. Most ITMs (55.6%) with pathologic
changes were associated with the horizontal position.
This was followed by the mesioangular (8.1%) and
distoangular (7.8%) positions (Table 4).
Discussion
Because racial variation, nature of one’s diet, de-
gree of use of masticatory apparatus, and genetic
inheritance can affect the jaw size, tooth size, and
facial growth, differences can be seen among studies
of the prevalence of third molar teeth performed in
different populations. Furthermore, differences in
Table 2. DISTRIBUTION OF PATIENTS WITH
IMPACTED THIRD MOLARS STRATIFIED BY GENDER
Gender Total (n) Patients With ITMs (n)
Women 198 89 (45)
Men 153 37 (24.2)
Total 351 126 (35.9)
␹2, 16.17; P ⫽ .0001.
Celikoglu, Miloglu, and Kazanci. Agenesis, Impaction, Angula-
tion of Third Molar Teeth. J Oral Maxillofac Surg 2010.
CELIKOGLU, MILOGLU, AND KAZANCI 993

Table 3. DISTRIBUTION OF IMPACTED THIRD

(12.0%). However, the frequency of congenital miss-
MOLARS IN JAW STRATIFIED BY GENDER AND ing third molars in the present study group was very
ANGULAR POSITION similar to that noted by Kruger et al13 for the New
Zealand population (15.2%) and that reported by Sis-
Location of Impacted Third Molar
man et al14 for the Turkish population (16.8%). Our
Variable Maxilla (%) Mandible (%) Total (%)
study found no significant gender differences in third
Gender (n) molar agenesis. This agrees with the results reported
Male 46 (42.6) 62 (57.4) 108 (20.9) by some other investigators.1,2 However, Daito et al15
Female 146 (43.5) 190 (56.5) 336 (52.1) showed that third molar agenesis was more common
Total 192 (43.2) 252 (56.8) 444 (38.2)
Angular position (n) in women than in men.
Vertical 113 (58.9) 22 (8.7) 135 (30.4) The frequency of third molar agenesis in the
Mesioangular 27 (14.1) 195 (77.4) 222 (50.0) present study was 63.5% for no absence of the third
Distoangular 48 (25.0) 3 (1.2) 51 (11.5) molars, 14.5% for the absence of 1 molar, 14.5% for
Horizontal 2 (1.0) 34 (13.5) 36 (8.1) the absence of 2 molars, 2.0% for the absence of 3
Total 192 (43.2) 252 (56.8) 444 (38.2)
molars, and 5.4% for the absence of all 4 molars. The
Data in parentheses are percentages. percentages from the present study were smaller than
Celikoglu, Miloglu, and Kazanci. Agenesis, Impaction, Angula- those reported by Sandhu and Kaur5 and Hattab et
tion of Third Molar Teeth. J Oral Maxillofac Surg 2010. al,16 who noted that three quarters of the subjects had
all 4 third molars. However, our percentages were
sample sizes, statistical methods, and diagnostic crite- greater than those reported by Hellman,17 who noted
ria can also explain these differences. The patients that one half of the subjects had all 4 third molars.
included in the present study were from a study According to Banks,18 it is most common for 2 third
sample representing patients of varied dietary habits molars to be missing, followed by 1, 4, and 3. The
and an average middle socioeconomic level from rural order of frequency for missing third molar teeth in the
and urban backgrounds. This ensured that the study present study was incompatible with the data re-
sample was representative of the Turkish orthodontic ported by Banks.18 In contrast, some studies14,17 have
population as a whole. reported the order of frequency for missing third
Massler et al10 reported that third molar calcifica- molar teeth to be 1, 2, 3, and 4 third molars.
tion starts at 7 to 10 years of age, calcification of the It has been reported that the selection of a popu-
crown is completed at 12 to 16 years of age, and lation sample for the investigation of ITMs is diffi-
eruption begins at 17 to 21 years of age. We examined cult.3,4 It requires creating a random sample of young
patients aged 20 to 26 years to determine the third adults from the general population; however, some
molar development and status of third molar impac- degree of bias exists owing to the difficulty in obtain-
tion. ing and taking radiographs, as well from an ethical
The frequency of third molar agenesis in the viewpoint. Taking a sample from the general popula-
present study was 17.3%, greater than that reported tion such as dental students probably also has some
by Levesque et al11 for the French-Canadians (9.0%) or degree of bias. Although our study had some bias
that reported by Venta et al12 for Finnish students regarding this point, our target population consisted

Table 4. DISTRIBUTION OF PATHOLOGIC CHANGES RELATED TO IMPACTED THIRD MOLARS STRATIFIED BY JAW
AND ANGULAR POSITION

Pathologic Changes (n)

Impacted Third Coronal Distal Cervical Distal Root Resorption Decreased Alveolar
Molars Radiolucency in ITM Caries on Adjacent Molar of Adjacent Molar Bone of Adjacent Molar Total

Jaw location
Maxilla 3 (1.6) 3 (1.6) 8 (4.2) 0 (0.0) 14 (7.3)
Mandible 3 (1.2) 7 (2.8) 9 (3.6) 13 (5.2) 32 (12.7)
Angular position
Vertical 3 (2.2) 0 (0.0) 0 (0.0) 1 (0.7) 4 (3.0)
Mesioangular 0 (0.0) 6 (2.7) 4 (0.0) 8 (3.6) 18 (8.1)
Distoangular 3 (5.9) 0 (0.0) 0 (0.0) 1 (2.0) 4 (7.8)
Horizontal 0 (0.0) 4 (11.1) 13 (13.9) 3 (8.3) 20 (55.6)
Total 6 (1.4) 10 (2.3) 17 (3.8) 13 (2.9) 46 (10.4)
Data in parentheses are percentages.
Celikoglu, Miloglu, and Kazanci. Agenesis, Impaction, Angulation of Third Molar Teeth. J Oral Maxillofac Surg 2010.
994 AGENESIS, IMPACTION, ANGULATION OF THIRD MOLAR TEETH
of persons with preoperative panoramic radiographs
and no referral for surgical removal of the third
molars.
The frequency of patients with ITMs in the present
study was 35.9% (24.2% of men and 45.0% of
women). This agreed with the findings from some
studies19,20 but contrasts with those from another
study.17 In the present study, 444 ITMs were ob-
served of 1,161 third molar teeth, for a frequency of
38.2%, with a greater frequency in women. This find-
ing was greater than that in other studies of the
general population.17,19,20 Shah et al,21 van der Linden
et al,22 and Kruger et al13 reported that ITMs were
observed with greater frequency in the mandible,
which agreed with our results. However, Björk et al19
and Hattab et al16 found a greater frequency of ITMs
in the maxilla.
In the present study, the most frequently observed
maxillary ITM was found in the vertical position
(58.9%), and this finding is consistent with that re-
ported by Venta et al23 (54.0%) but greater than that
reported by Kruger et al13 (18.1%) and Sandhu and
Kaur5 (43.0%). Our observation that 25.0% of upper
ITMs were in the distoangular position is close to the
rate reported by Venta et al23 but greater than that
reported by Kruger et al.13 The frequency of mesio-
angular maxillary ITMs (14.1%) in our study was
greater than that reported by Sandhu and Kaur5
(9.0%). The present study showed that 77.4% of the
mandibular ITMs were in the mesioangular position.
This value is considerably greater than that reported
by Sandhu and Kaur5 (49.0%) and Sewerin and von
Wowern24 (18.0%) but close to that noted by Venta et
al23 (71.0%). Our observation that 8.7% of the man-
dibular ITMs were in the vertical position is consid-
erably less than the rate reported by Sandhu and
Kaur5 (42.0%). The frequency of distoangular mandib-
ular ITMs was less than that reported by Sandhu and
Kaur5 (9.0%). The frequency of horizontal maxillary
and mandibular ITMs was greater than that re-
ported by Sandhu and Kaur5 and van der Linden et
al22 (17.2%).
Polat et al3 (26.5%) and Al-Khateeb and Bataineh4
investigated caries in third molar teeth on panoramic
radiographs. However, the presence of additional
pathologic features such as occlusal caries is difficult
to detect on panoramic radiographs alone, and a clin-
ical examination is required. Therefore, the presence
of caries in the third molars was not evaluated in our
study. In the present study, the pathologic changes
most frequently observed were distal root resorption
of an adjacent molar, with a frequency of 3.8%. The
other pathologic changes included decreased alveolar
bone of an adjacent molar in 2.9% and distal cervical
caries on an adjacent molar in 2.3%. It was thought
these changes occur in the second molars because of
the relative inaccessibility for routine oral hygiene
procedures, which allows a build-up of plaque and
entrapment of food. When evaluating all the patho-
logic changes caused by ITMs, the results showed that
only 10.4% of ITMs caused at least one of the 4
pathologic changes, and this frequency was appar-
ently low. Polat et al3 (26.5%) and Al-Khateeb and
Bataineh4 (46.4%) showed that the prevalence of
pathologic sequela due to ITMs was greater than our
results showed. However, samples of surgical patients
were included in both investigations. Eliasson et al25
detected in randomly selected patients that 6.9% of
ITMs were associated with pathologic conditions. In
most of the detected pathologic changes in the
present study, the positions of the ITMs were hori-
zontal; in contrast, vertical ITMs had a low risk. This
agreed with the results from Venta et al12 and Polat et
al.3 Knutsson et al26 found that a horizontal molar that
is completely covered by soft tissue is more suscepti-
ble to cystic changes than other mandibular third
molars. The present study found that horizontal and
mesioangular ITMs had a high risk of distal cervical
caries on an adjacent molar, distal root resorption of
an adjacent molar, and decreased alveolar bone of an
adjacent molar.
Kim et al27 suggested that premolar extraction ther-
apy reduces the frequency of ITMs because of in-
creased eruption space concomitant with mesial
movement of the molars during space closure. Björk
et al19 showed that the third molar was associated not
only with a reduced amount of growth, but also with
a more downward instead of a forward growth direc-
tion. Ricketts28 believed that the space was made for
the normally developing third molar by a forward
direction of tooth eruption rather than resorption at
the anterior border of the ramus. These findings seem
to indicate that a third molar will erupt if space is
available and that its impaction is a manifestation of a
tooth/tissue disharmony or crowding.
All ITMs are potentially pathologic; therefore, pro-
phylactic removal eliminates the risk of future dis-
ease. In addition, removal during young adulthood
reduces the risks of operative and postoperative com-
plications compared with removal in older patients.
In contrast, the presence of third molars can cause late
crowding.29,30 It is unreasonable to ignore the orthodon-
tic issues related to third molars, especially in orthodon-
tic patients, who have made the investment to achieve
an ideal occlusion. Part of a complete orthodontic treat-
ment plan should include a recommendation regarding
third molars. The plan should include rationale and
recommendations for their removal according to the
orthodontic treatment objectives.
The present study showed that agenesis accounted
for 17.3% of pathologic features related to third molar
teeth and impacted teeth accounted for 35.9% in
CELIKOGLU, MILOGLU, AND KAZANCI
Turkish orthodontic patients aged 20 to 26 years.
Mesioangular inclination was seen in 50.0%, and a
small proportion (10.4%) were pathologic changes of
ITMs.
Acknowledgments
We would like to express our sincere gratitude to Lecturer Ali
Çağlar Güllüce for his support in proofreading our report and to
Assistant Professor Hamit Acemoğlu for his statistical evaluation.
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