ORIGINAL ARTICLE

Orthodontists’ and surgeons’ opinions on the

role of third molars as a cause of
dental crowding
Steven J. Lindauer,a Daniel M. Laskin,b Eser Tüfekçi,c Russell S. Taylor,d Bryce J. Cushing,d
and Al M. Beste
Richmond, Va

Introduction: Despite a substantial body of literature refuting an association between third molar eruption
and crowding of the anterior dentition, the issue continues to be controversial. Methods: A survey was
developed to evaluate and compare the current opinions of orthodontists (n ⫽ 393) and oral and maxillofacial
surgeons (n ⫽ 458) regarding the link between third molars and the development of anterior crowding.
Results: A smaller percentage of orthodontists than surgeons believed that maxillary (P ⬍.0001) and
mandibular (P ⬍.0001) third molars produce anterior forces during eruption. Similarly, orthodontists were less
likely to think that maxillary (P ⬍.0001) and mandibular (P ⬍.0001) third molars cause anterior crowding and
were therefore less likely to recommend prophylactic removal of maxillary (P ⬍.0001) and mandibular (P
⬍.0001) third molars to prevent crowding. Surgeons were more likely to “generally” or “sometimes” (56.9%)
recommend prophylactic removal of mandibular third molars to prevent crowding, whereas orthodontists
more often said that they “rarely” or “never” (64.4%) recommend it. Differences in orthodontists’ and oral and
maxillofacial surgeons’ beliefs about the association between third molar eruption and the development of
crowding were significantly related to graduation year. More recently graduated orthodontists were less likely
to recommend prophylactic removal of third molars to prevent crowding, and surgeons were more likely to
recommend removal if they graduated in the 1970s or 1980s. Conclusions: Significant disagreement exists
among practitioners, including both orthodontists and oral and maxillofacial surgeons, regarding the
fundamental issues underlying the role of third molars in dental crowding. (Am J Orthod Dentofacial Orthop
2007;132:43-8)

D
espite numerous attempts to clarify the role of
third molars in causing late anterior dental
crowding, the issue remains controversial.
Many dental practitioners apparently believe that the
eruption of third molars can be a causative factor in the
development of this condition. Moreover, orthodontic
patients and their parents are often concerned that third
molars will threaten the stability of orthodontic results,
and former patients frequently cite the eruption of third
From the School of Dentistry, Virginia Commonwealth University, Richmond.
a
Professor and Chair, Department of Orthodontics.
b
Professor and Chairman Emeritus, Department of Oral and Maxillofacial
Surgery.
c
Assistant professor, Department of Orthodontics.
d
Dental student.
e
Associate professor, Department of Biostatistics.
Supported in part by the Medical College of Virginia Orthodontic Education
and Research Foundation.
Reprint requests to: Steven J. Lindauer, Department of Orthodontics, School of
Dentistry, Virginia Commonwealth University, PO Box 980566, Richmond,
VA 23298-0566; e-mail, sjlindau@vcu.edu.
Submitted, March 2005; revised and accepted, July 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.07.026
molars as causing redevelopment of their malocclu-
sions.
The issue has been extensively reviewed in the
literature, and various authors have come to different
conclusions regarding the extent to which third molars
are causative agents in the development of late anterior
crowding of the dentition. Richardson,1 who had per-
formed many studies on crowding and third molars,
concluded in her review of the relevant literature that
“The evidence outlined . . . implicates pressure from
the back of the arch and presence of a third molar in the
cause of late lower arch crowding.” However, she
qualified her statement by saying that other factors
might also be involved. Bishara,2 on the other hand,
citing much of the same literature, stated “In summary,
one has to conclude from the available data that third
molars do not play a significant, ie, quantifiable, role in
mandibular anterior crowding.”
Similarly, Beeman,3 in her article making a case for
routine removal of third molars in adolescents, stated
with regard to many previous studies on the subject that
“The results have supported both sides of the contro-
versy, convincing most dental practitioners that pres-
43
44 Lindauer et al
sure from third molars is clearly not the only factor in
the development of mandibular crowding.” Hicks,4 in
his counterpoint article arguing against prophylactic
removal of third molars, offered 2 statements represent-
ing opposing viewpoints: “The presence of third molars
can cause late crowding,” and “Although some inves-
tigators have shown a statistical association of third
molars and late anterior crowding, the association is not
strong enough to allow prediction of patients at risk.”
Song et al5 concluded, after reviewing 40 studies on the
topic, that “there is no reliable research evidence to
support the prophylactic removal of disease-free im-
pacted third molars.”
Several studies concluded that the long-held belief
that erupting third molars cause crowding of the inci-
sors after orthodontic alignment should be questioned.
Ades et al6 examined orthodontic patients at 10 years
postretention and determined that there were no differ-
ences in alignment of the incisors in those with bilat-
erally impacted, erupted, extracted, or absent third
molars. In a randomized clinical trial in which postorth-
odontic patients were assigned to third molar extraction
and nonextraction groups, Harradine et al7 found sig-
nificantly decreased arch length in the nonextraction
group but no significant differences in crowding be-
tween groups as evaluated by the irregularity index8 at
a minimum of 5 years postretention. Van der Shoot et
al9 found no differences in the irregularity index in
orthodontically treated patients at postretention with
erupted, nonerupted, extracted, or congenitally absent
third molars. Similarly, Al-Balkhi10 found no associa-
tion between condition of the manidublar third molars
and lower anterior crowding in a postorthodontic sam-
ple of patients without tight interproximal incisal con-
tacts.
Laskin11 reported in 1971 that approximately 65%
of both orthodontists and oral surgeons subscribed to
the idea that unerupted third molars produced an
anteriorly directed force and should be removed to
prevent development of crowding of the mandibular
incisors. Because of the ongoing state of the contro-
versy and the consequences of believing that third
molars cause crowding, the purpose of this study was to
evaluate and compare the current opinions of orthodon-
tists and oral and maxillofacial surgeons regarding the
link between erupting third molars and anterior crowd-
ing of the dentition.
MATERIAL AND METHODS
A short survey consisting of 6 questions related to
the role of third molars as a cause of dental crowding
was developed. The questions are shown in Figure 1.
Institutional Review Board approval was granted to
American Journal of Orthodontics and Dentofacial Orthopedics
July 2007
Fig 1. Survey questions.
conduct the study, and the questionnaire was sent to
871 orthodontists and 913 oral and maxillofacial sur-
geons throughout the United States. Names were sys-
tematically chosen from lists provided by the respective
specialty organizations and sorted by zip code to assure
an even geographic distribution of participants. The
surveys were sent by first-class mail with addressed
postage-paid return envelopes. A short, explanatory
letter requesting voluntary participation was included.
There were no identifying markers on the surveys to
trace answers back to individual respondents, and no
follow-up questionnaires were sent to nonrespondents.
Chi-square analysis was used to determine differ-
ences in the responses to the questions between orth-
odontists and oral and maxillofacial surgeons. Logistic
regression was used to determine whether there was a
relationship between answers to the questions and year
of graduation.
RESULTS
A total of 851 (48%) surveys were returned. There
were 393 responses from orthodontists (45% response
rate) and 458 responses from oral and maxillofacial
surgeons (50% response rate). Answers to all questions
were significantly different between the 2 groups.
Results from the first 2 questions regarding force
exerted during eruption by maxillary and mandibular
third molars are shown in Table I. Fewer orthodontists
than surgeons answered that maxillary (P ⬍.0001) and
mandibular (P ⬍.0001) third molars produce an ante-
rior component of force during eruption. Twenty-eight
percent of orthodontists vs 19.4% of surgeons (P
⬍.0005) thought that mandibular but not maxillary
third molars produce force during eruption, whereas no
orthodontists and only 1 surgeon believed that only
maxillary molars produce force.
The second set of questions asked whether erupting
maxillary or mandibular third molars cause crowding of
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
Table I. Answers to question “do erupting third molars
exert anterior force?”
Yes No
Orthodontists
Maxilla 112 (29.6%) 266 (70.4%)
Mandible 218 (57.7%) 160 (42.3%)
Surgeons
Maxilla 255 (59.0%) 177 (41.0%)
Mandible 338 (78.2%) 94 (21.8%)
the respective anterior dentitions. The results are shown
in Table II. Answers between orthodontists and sur-
geons were significantly different for both maxillary (P
⬍.0001) and mandibular (P ⬍.0001) third molars. For
the maxillary teeth, orthodontists were more likely than
surgeons to state that these third molars “never” cause
crowding, and they were also less likely to say that they
“sometimes” cause crowding. In the mandible, orth-
odontists were less likely than surgeons to report that
third molars “frequently” cause crowding and more
likely to say that they “rarely” or “never” cause
crowding.
The last set of questions asked whether the respon-
dent recommended prophylactic removal of third mo-
lars to prevent crowding of the anterior dentition. The
results are shown in Table III. There were significant
differences between orthodontists and surgeons regard-
ing removal of both maxillary (P ⬍.0001) and mandib-
ular (P ⬍.0001) third molars to prevent crowding. For
both maxillary and mandibular third molars, orthodon-
tists were less likely than surgeons to “generally”
recommend removal and more likely to “never” recom-
mend removal.
Effect of year of graduation
The relationship between graduation year and the
combination of answers given by orthodontists and oral
and maxillofacial surgeons to the first 2 questions about
whether anterior force is exerted by erupting maxillary
and mandibular third molars is shown in Figure 2.
There was no significant relationship between gradua-
tion year and the answers to these questions by orth-
odontists (P ⬎.25), but surgeons showed a significant
association between their answers and graduation years
(P ⬍.0001). The probability that surgeons would an-
swer “yes” to both maxillary and mandibular third
molars producing an anterior force changed as a func-
tion of graduation year; it was highest for graduates in
the 1980s and declined in both earlier and later gradu-
ates.
There were significant associations between gradu-
ation year and the opinions of both orthodontists (P
Lindauer et al 45
⬍.005) and surgeons (P ⬍.0005) regarding whether
maxillary third molars cause crowding of the dentition.
Orthodontists graduating in the 1970s were more likely
to answer “rarely” and less likely to answer “never”
than earlier or later graduates. Surgeons graduating
around 1980 were more likely to answer “rarely” or
“sometimes” and less likely to answer “never” than
earlier or later graduates.
There were also significant relationships for both
orthodontists (P ⬍.005) and surgeons (P ⬍.0001)
between graduation year and whether they thought that
mandibular third molars cause crowding. Orthodontists
graduating in the late 1970s were more likely to answer
“sometimes” and less likely to answer “never” than
earlier or later graduates. There was also a trend for
earlier orthodontic graduates to be more likely to
answer “frequently” and later graduates to answer
“rarely.” Surgeons graduating around 1970 were more
likely to answer “frequently,” and those graduating in
the late 1980s were more likely to answer “sometimes”
than earlier or later graduates. Those graduating in the
early 1980s were less likely than earlier or later
graduates to answer “never” or “rarely.”
The likelihood that both orthodontists (P ⬍.001)
and surgeons (P ⬍.005) would recommend prophylac-
tic removal of maxillary third molars to prevent crowd-
ing was significantly related to graduation year. For
orthodontists, it became more likely that they would
“never” and less likely that they would “rarely” recom-
mend prophylactic removal of maxillary molars as
graduation year became more recent. For surgeons, the
likelihood they would “never” recommend prophylac-
tic removal was lowest, and the likelihood that they
would “rarely” or “sometimes” recommend removal to
prevent crowding was highest for those graduating
around 1980 than earlier or later graduates.
There were also significant associations between
graduation year and whether orthodontists (P ⬍.0001)
and surgeons (P ⬍.0001) would recommend prophy-
lactic removal of mandibular third molars to prevent
crowding. Orthodontists were more likely to “never”
and less likely to “generally” or “sometimes” recom-
mend prophylactic removal of mandibular third molars
as the graduation year became more recent. Surgeons
graduating around 1970 were more likely to “gener-
ally” recommend removal of mandibular third molars
than earlier or later graduates. Those graduating in the
early 1980s were less likely to “never” recommend
removal, and those graduating in the late 1980s were
more likely to “sometimes” recommend removal of
mandibular third molars prophylactically to prevent
crowding.
46 Lindauer et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2007

Table II. Answers to question “do erupting third molars cause anterior crowding?”
Frequently Sometimes Rarely Never

Orthodontists
Maxilla 2 (0.5%) 54 (13.9%) 177 (45.6%) 155 (39.9%)
Mandible 28 (7.2%) 126 (32.5%) 127 (32.7%) 107 (27.6%)
Surgeons
Maxilla 25 (6.4%) 149 (38.4%) 184 (47.4%) 94 (24.2%)
Mandible 128 (28.3%) 161 (35.6%) 99 (21.9%) 64 (14.2%)

Table III. Answers to question “do you recommend removal of third molars to prevent anterior crowding?”
Generally Sometimes Rarely Never

Orthodontists
Maxilla 30 (7.6%) 34 (8.7%) 102 (26.0%) 227 (57.8%)
Mandible 70 (17.8%) 70 (17.8%) 83 (21.1%) 170 (43.3%)
Surgeons
Maxilla 99 (21.8%) 78 (17.1%) 142 (31.2%) 136 (29.9%)
Mandible 176 (38.7%) 83 (18.2%) 101 (22.2%) 95 (20.9%)

practitioners. This was demonstrated by the wide range

Fig 2. Relationship between opinion of whether erupt-
ing third molars produce anterior force and year of
graduation for orthodontists (not significant, P ⬎.25)
and surgeons (P ⬍.0001).
DISCUSSION
The role of third molars in creating an anterior
component of force during eruption capable of produc-
ing crowding is a controversial topic among dental
of opinions expressed by both the orthodontists and the
oral and maxillofacial surgeons surveyed in this study.
The survey showed significant differences between
the opinions of orthodontists and surgeons regarding
the role of third molars in causing crowding of the
anterior teeth. Surgeons were more likely than orth-
odontists to think that both maxillary and mandibular
molars exert anterior components of force on the
dentition during eruption, more likely to believe that
erupting third molars cause crowding, and more likely
to recommend prophylactic removal of third molars to
prevent crowding of both the maxillary and mandibular
teeth. It is not surprising to find such differences in
opinion regarding this controversial topic, but it is
interesting that there was such a consistent difference in
the opinions between the 2 specialty groups. The
routine removal of asymptomatic third molars has been
widespread for decades. Without clear justification for
continuing this practice,5,12 surgeons might be more
likely or more willing to rationalize their decision to
extract asymptomatic third molars.
Although the focus of this study was on whether
practitioners recommended removal of third molars to
prevent late anterior crowding, the literature also ques-
tions whether asymptomatic third molars should be ex-
tracted for other purposes. It is generally agreed that third
molars should be removed when there are symptoms or
when pathology is present. However, in the absence of
pathology, 2 recent comprehensive reviews concluded
that it might be more logical to just monitor the third
molars over time.5,12 These recommendations were based
on an absence of data documenting the onset of pathology
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
related to these teeth, along with the known risks of
postoperative morbidity and the high costs of removal.
Since 1971, when 65% of both orthodontists and
surgeons reportedly recommended prophylactic re-
moval of mandibular third molars to prevent incisor
crowding,11 the prevalence of belief in the association
between third molars and dental crowding has de-
creased. In this survey, 38.9% of the orthodontists and
56.9% of the oral and maxillofacial surgeons answered
that they “generally” or “sometimes” recommend re-
moval of mandibular third molars to prevent crowding.
For both orthodontists and surgeons, there was
substantial consistency between the belief in force of
eruption causing crowding and the recommendation for
prophylactic removal of third molars to prevent crowd-
ing. However, the pattern of agreement between an-
swers to the questions was different for orthodontists
and surgeons. Analysis of the data collected to evaluate
the level of consistency between answers to various
questions showed that 77.9% of orthodontists believed
that maxillary third molars “rarely” or “never” cause
crowding, so they “rarely” or “never” recommend
removal. For surgeons, this percentage was smaller
(54.8%). For surgeons, 32.1% believed that maxillary
third molars “frequently” or “sometimes” cause crowd-
ing, so they “generally” or “sometimes” recommend
removal. For orthodontists, this percentage was only
8.7%. For mandibular third molars, 54.5% of orthodon-
tists believed that they “rarely” or “never” cause
crowding, so they “rarely” or “never” recommend
removal. The “rarely” or “never” percentage was
34.0% for surgeons. More oral and maxillofacial sur-
geons believed that mandibular third molars “fre-
quently” or “sometimes” cause crowding and were
consistent by “generally” or “sometimes” recommend-
ing their removal. The percentages were 55.0% for
surgeons and 30.3% for orthodontists.
Specialists who expressed the belief that neither
maxillary nor mandibular third molars produce anterior
force during eruption were also very likely (84.0%) to
say that they “rarely” or “never” cause crowding, and
therefore “rarely” or “never” recommend removal. Of
those who answered that both maxillary and mandibu-
lar third molars do produce force during eruption,
however, only 43.7% followed through by saying that
they recommend removal of those teeth “generally”
or “sometimes.” Indeed, 29.5% of them said that they
“rarely” or “never” recommend removal. Likewise,
only 44.7% of those who responded that maxillary
third molars do not produce force, but mandibular
third molars do, also said that maxillary third molars
should “rarely” or “never” be removed, and mandib-
ular third molars should “generally” or “sometimes”
Lindauer et al 47
be removed to prevent crowding. From these data, it
appears that specialists who believe that third molars do
not produce an anterior force during eruption consis-
tently and decisively believe that they do not cause
crowding and should therefore not be extracted. In
contrast, those who thought that third molars do exert
force were about equally likely to express that this force
will or will not cause crowding, and that removal of
those teeth should or should not be recommended.
Both orthodontists and oral and maxillofacial sur-
geons were more likely to implicate mandibular molars
than maxillary molars as a cause of force and crowding,
and were therefore more likely to recommend their
removal. This is consistent with literature on the topic,
which more often focuses on the crowding potential of
mandibular than maxillary third molars.1-4,6,7,10,11,13
The relationship between year of graduation and the
belief that third molars cause crowding and should
therefore be removed prophylactically was somewhat
different between orthodontists and surgeons. Recent
graduates in both groups were less likely to recommend
removal to prevent incisor crowding, indicating famil-
iarity with current literature on this topic. Surgeons
graduating before 1970, however, were also less likely
to recommend removal prophylactically, possibly re-
flecting a difference in their original education or a
better ability to keep up with current literature.
CONCLUSIONS
Despite an extensive body of literature addressing this
topic, the question of whether third molars should be
removed to prevent future crowding of the anterior den-
tition still is controversial. The results of this survey
demonstrate significant disagreement among practitioners,
including both orthodontists and oral and maxillofacial
surgeons, regarding the fundamental issues underlying
this controversy. Surgeons were significantly more likely
than orthodontists to believe that erupting third molars
produce an anterior component of force and cause crowd-
ing of the anterior dentition, and were therefore more
likely to recommend prophylactic removal of third molars
to prevent crowding. Mandibular third molars were more
consistently implicated than maxillary third molars as a
cause of crowding and were therefore more likely to be
recommended for removal by both orthodontists and oral
and maxillofacial surgeons.
Opinions about the role of third molars in causing
crowding of the anterior dentition were significantly
related to year of graduation for both orthodontists and
oral and maxillofacial surgeons. Generally, orthodon-
tists became less likely to believe that third molars
caused crowding and were less likely to recommend
their removal prophylactically when they graduated
48 Lindauer et al
more recently from orthodontic programs. This agrees
with most recent literature on the topic that suggests
little association between the eruption of third molars
and crowding of the anterior teeth. Surgeons were more
likely to believe that third molars caused crowding and
more likely to recommend their removal to prevent
crowding if they graduated in the 1970s or 1980s than
earlier or later graduates.
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