Abstract
Background
Elongated third molars have been associated with occlusal interference, mandibular deviation, and temporomandibular joint (TMJ) disorders. However, their impact on TMJ space morphology and posterior tooth wear remains insufficiently explored.
Objective
This study aimed to assess the relationship between unilateral third molar elongation, TMJ space asymmetry, and asymmetrical posterior tooth wear.
Methods
Thirty patients presenting with unilateral third molar elongation (experimental group) and 30 controls with fully aligned dentition and absent third molars were included (Ethical approval ID:2023015). Cone-beam computed tomography (CBCT) was utilized to measure anterior, superior, and posterior TMJ spaces. Some of these CBCT scans were obtained specifically for this study. Some of CBCT scans were taken for therapeutic purposes. Bilateral differences in mean wear index (DBMWI) and the mean standard deviation (MSD) of posterior tooth wear were calculated using Lagan’s modified scoring system. Statistical analysis was conducted using SPSS 22.0.
Results
Significant intergroup differences in TMJ space asymmetry (ΔAS, ΔSS, and ΔPS) were observed (p < 0.05). The experimental group demonstrated higher DBMWI (0.50 ± 0.30 vs. 0.19 ± 0.14, p = 0.015) and MSD values (0.81 ± 0.30 vs. 0.36 ± 0.16, p = 0.001), indicating more pronounced irregular posterior tooth wear.
Conclusion
Unilateral elongation of the third molar is associated with TMJ space asymmetry and increased posterior tooth wear. Early intervention, including extraction of the elongated third molar, may help prevent occlusal imbalance and related complications such as tooth fractures.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-026-08560-8.
Keywords: Third molar, Temporomandibular joint, Tooth wear, Cone-beam computed tomography, Diagnostic imaging
Introduction
Impacted third molars are frequently extracted due to complications such as caries and pericoronitis. In contrast, asymptomatic or properly erupted third molars are often retained, which may lead to elongation resulting from disrupted occlusal equilibrium. This elongation is further influenced by the higher impaction rates observed in mandibular third molars, agenesis of maxillary third molars, and selective extraction patterns [1–6].
Elongated third molars tend to establish premature distal occlusal contacts, disrupting mandibular kinematics and contributing to the development of temporomandibular disorders (TMD) [7–9]. Although the causal relationship between occlusal interference and TMD remains debated [10], several studies have reported associated mandibular deviation and asymmetrical masticatory muscle activity [11–14]. Moreover, sustained occlusal interference can intensify localized attrition of the opposing dentition. Despite this, comprehensive analyses addressing TMJ space asymmetry and patterns of posterior tooth wear are limited.
Clinical observations have consistently revealed that patients exhibiting unilateral third molar elongation often present with asymmetrical occlusal wear across the posterior dentition, prompting the design of this study to substantiate the correlation.
Case and methods
Study design and participants
A case-control study was conducted at Guangzhou Twelfth People’s Hospital between March 2023 and May 2025. Participant selection followed the PICO framework, enrolling 30 individuals with unilateral third molar elongation (experimental group) and 30 age- and sex-matched controls. Ethical approval was granted (ID: 2023015). All participants were informed of the experimental progress and written informed consent was obtained from all participants.
Inclusion Criteria:
Experimental group: Good overall oral health, unilateral third molar elongation with clinically evident occlusal interference, no history of bruxism or orthodontic treatment.
Control group: Fully aligned dentition, and healthy periodontal condition. No history of temporomandibular joint dysfunction or orthodontic treatment, and healthy periodontal condition.
CBCT imaging and measurements
Bilateral temporomandibular joints were imaged using MEYER CBCT (Hefei Meiya Optoelectronic Technology Company, China; field of view: 17 × 11 cm; slice thickness: 0.2 mm). Joint space dimensions anterior (AS), superior (SS), and posterior (PS) were assessed following Ikeda’s method [15] (Fig. 1). In the CBCT temporomandibular joint area, we selected the largest cross-sectional slice of the condyle, and made an oblique sagittal cut parallel to the long axis of the condyle.
Using the true horizontal line (THL) at the top of the joint fossa as the standard reference line and the intersection point of THL and the top of the joint fossa was section of fossa (SF);
The vertical distance from SF to the top of the condyle was the superior joint space (SS);
Drawing a tangent from SF to the anterior oblique surface of the condyle intersected at anterior oblique surface of the condyle (AC), and drawing a perpendicular line from AC to the anterior oblique surface of the joint fossa, the vertical distance was the anterior joint space (AS);
Drawing a perpendicular line from SF to the posterior oblique surface of the condyle, the vertical distance was the posterior joint space (PS). For the same subject, if the deviation between two measurements was ≤1mm, if it was >1mm, a third measurement was performed, and the final measurement result was the intermediate value of the two closest measurements.
Side-specific differences (ΔAS, ΔSS, and ΔPS) were subsequently calculated to evaluate spatial asymmetry.
Fig. 1.
Method to measure the temporomandibular joint space. A The measurement method proposed by Kazumi Ikeda, a schematic diagram. B Showed the right joint, AS:1.63 mm, SS:2.68 mm, PS:1.55 mm (C) Showed the left joint, AS:2.07 mm, SS:4.42 mm, PS:2.52 mm
Tooth wear assessment
Wear status of occlusal surfaces from first premolar to second molar was evaluated using Lagan’s modified scoring index [16] (Fig. 2), which grades each cusp quadrant on a 0–9 scale based on the extent of dentin exposure:
0: No visible wear;
1: Enamel wear only, no dentin exposure;
2: Focal dentin exposure < 1%;
3: Dentin exposure between 1%–24%;
4: Dentin exposure 25%–50%, surrounded by enamel;
5: Dentin exposure 45%–60%, across cusp tip;
6: Dentin exposure 50%–75%, unilateral maximal area;
7: Extensive dentin exposure (60%–85%) with thick peripheral enamel;
8: Nearly complete dentin exposure (85%–99%) with thin enamel margins;
9: Full dentin exposure, no remaining enamel
Fig. 2.
Application of Lagan’s modified quadrant-based scoring system for posterior tooth wear. A Conceptual diagram of the method. The occlusal surface is partitioned into quadrants aligned with the cusps. Each quadrant receives a score from 0 (no wear) to 9 (complete dentin exposure) based on the percentage of dentin visible. B-E Practical scoring examples on different posterior teeth: (B,C) Four-cusp molars with mean wear indices of 5 and 6, respectively (SD = 1.58 for both). D Five-cusp molar with a mean wear index of 2.4 (SD = 0.49). E Two-cusp premolar with a mean wear index of 6.5 (SD = 1.5)
Quadrant scores were summed, and the mean value for each quadrant was recorded as the abrasion index, with the corresponding standard deviation documented as the standard deviation index.
Following the calculation of abrasion and standard deviation indices for all posterior teeth, values for the left and right sides were computed separately. The difference between the bilateral mean wear indices was defined as the DBMWI.
The standard deviation indices of all posterior teeth were then aggregated per subject, and the mean value (MSD) was used to assess intergroup differences in wear variability between the experimental and control groups.
Statistical analysis
All data were analyzed using SPSS 22.0. Intergroup comparisons were conducted using independent t-tests or Mann-Whitney U tests, depending on data distribution. Statistical significance was defined as p < 0.05. Inter-examiner reliability was assessed using Spearman’s rank correlation coefficient. All correlation coefficients exceeded 0.80 (p < 0.001), indicating strong positive correlations between the two examiners for all joint space measurements.
Results
Participant characteristics
No significant differences in age (40.21 ± 9.48 vs. 40.00 ± 12.11) or gender distribution (p = 1.000) were observed between the experimental and control groups. This confirms successful matching for these demographic variables (Table 1).
Table 1.
Comparison of general data
| Indicators | Experimental group (n = 30) | Control group (n = 30) | P-values |
|---|---|---|---|
| Age | 40.21 ± 9.48 | 40 ± 12.11 | 0.947 |
| Gender (male/female) | 16/14 | 16/14 | 1 |
Temporomandibular joint space asymmetry
Significant differences in bilateral TMJ space asymmetry were observed between the groups. The Mann-Whitney U test results are presented in Table 2. The experimental group demonstrated significantly greater median differences in all joint spaces compared to the control group: anterior space (ΔAS: 0.60 mm vs. 0.24 mm, U = 147.5, p = 0.010, r = 0.453), superior space (ΔSS: 0.55 mm vs. 0.33 mm, U = 194.5, p = 0.022, r = 0.324), and posterior space (ΔPS: 0.50 mm vs. 0.28 mm, U = 203.0, p = 0.033, r = 0.301). The effect sizes (r) indicate medium to large magnitudes of difference (Fig. 3). Normal distribution test (Table S1). Inter-examiner reliability was assessed using Spearman’s rank correlation coefficient. The analysis revealed statistically significant positive correlations between the two examiners for all TMJ space measurements (anterior, superior, and posterior joint spaces; p < 0.001 for all), confirming consistent and reliable measurements. These results support the reproducibility of the imaging assessment protocol used in this study.
Table 2.
Comparison of bilateral TMJ space asymmetry indices between groups
| Indicators | Groups | IQR | Median | Mann-Whitney U | P values | r |
|---|---|---|---|---|---|---|
| ΔAS | Experimental group (n = 30) | 0.65 | 0.6 | 147.5 | 0.01 | 0.453 |
| Control group (n = 30) | 0.48 | 0.24 | ||||
| ΔSS | Experimental group (n = 30) | 0.9 | 0.55 | 194.5 | 0.022 | 0.324 |
| Control group (n = 30) | 0.38 | 0.33 | ||||
| ΔPS | Experimental group (n = 30) | 1 | 0.5 | 203 | 0.033 | 0.301 |
| Control group (n = 30) | 0.38 | 0.28 |
r = Z/√N (interpretation: ~0.1 small, ~ 0.3 medium, ~ 0.5 large effect)
IQR Interquartile Range
Mann-Whitney U test
Fig. 3.
Shows the comparison of ΔAS, ΔSS and ΔPS in experimental and control group
Posterior tooth wear
The analysis of posterior tooth wear revealed significant intergroup differences in both the bilateral and intra-tooth wear patterns. As detailed in Table 3, the experimental group exhibited significantly higher median values for both indices compared to the control group. The Difference in Bilateral Mean Wear Index (DBMWI) was greater in the experimental group (Median = 0.37, IQR = 0.54) than in controls (Median = 0.19, IQR = 0.31; U = 187.5, p = 0.015, r = 0.343). A more pronounced difference was observed in the Mean Standard Deviation (MSD), a measure of intra-tooth wear variability, with the experimental group showing a median of 0.82 (IQR = 0.37) versus 0.37 (IQR = 0.22) in the control group (U = 47.0, p = 0.001, r = 0.729). The associated effect sizes (r) indicate a medium effect for DBMWI and a large effect for MSD (Fig. 4).
Table 3.
Comparison of DBMWI and MSD between the experimental and control groups
| Indicators | Groups | IQR | Median | Mann-Whitney U | P values | r |
|---|---|---|---|---|---|---|
| DBMWI | Experimental group (n = 30) | 0.54 | 0.37 | 187.5 | 0.015 | 0.343 |
| Control group (n = 30) | 0.31 | 0.19 | ||||
| MSD | Experimental group (n = 30) | 0.37 | 0.82 | 47 | 0.001 | 0.729 |
| Control group (n = 30) | 0.22 | 0.37 |
r = Z/√N (interpretation: ~0.1 small, ~ 0.3 medium, ~ 0.5 large effect)
IQR Interquartile Range, DBMWI Difference in Bilateral Mean Wear Index, MSD Mean Standard Deviation of wear
Mann-Whitney U test
Fig. 4.
Shows the comparison of DBMWI and MSD of experimental and control group
Discussion
In this study, significant differences in TMJ space asymmetry were observed between the unilateral third molar elongation group and the control group, indicating that unilateral third molar elongation has a notable impact on TMJ position. Specifically, significant differences in anterior, superior, and posterior joint space differences were found between the experimental and control groups, suggesting that the presence of an elongated unilateral third molar significantly influences temporomandibular joint deviation. However, due to the limited sample size, the data exhibited a skewed distribution, resulting in certain limitations in the conclusions drawn. Based on the calculated results, the difference of anterior joint space had a r value of 0.453, and the mean of standard deviation had a r value of 0,729, both of them showed a large effect in the nonparametric test. In this study, the observed significant differences in ΔAS, ΔSS, and ΔPS between the experimental and control groups indicate that unilateral elongation of the third molar disrupts the symmetry of the temporomandibular joint and contributes to a certain degree of torsion.
The condylar position refers to the relationship of the condyle within the articular fossa when the teeth are in centric occlusion. This position is influenced by several factors, including growth remodeling, functional activities, occlusal changes, and physiological adaptations. Previous studies on normal populations have shown that the condyle generally occupies a neutral position within the joint fossa, with the posterior joint space being slightly larger than the anterior joint space [17].
Therefore, when the joint is deviated, the difference between the corresponding joint spaces on both sides will increase, if the joint is deviated to the left in the coronal position, the supra joint space of the left side will decrease, while the supra joint space on the right side will increase. This method enlarges the difference of a deviated position, contrasting to the difference near to zero of the neutral position.
Previous studies have shown that when the unilateral elongated third molar has early contact with the contralateral second molar, it can lead to occlusal interference [9, 18, 19]. This condition creates an imbalance in the strength of both chewing muscles, which in turn affects the normal positioning of the mandibular condyle within the temporomandibular joint fossa.
Therefore, elongation of the third molar is not just a localized issue it may also cause significant structural changes in the temporomandibular joint, particularly alterations in the joint space.
Analysis of posterior tooth wear (from the first premolar to the second molar) revealed significant differences in DBMWI and MSD between the experimental and control groups. This indicates that unilateral third molar elongation causes unequal occlusal wear, not only between the left and right sides but also across individual tooth surfaces. Guo Shaoyong’s analysis of bilateral T-SACN and electromyographic data from the temporalis and masseter muscles found that in cases of unilateral third molar elongation with occlusal interference, there was an imbalance in the strength of the bilateral temporalis muscles during lateral occlusion, with the elongated side showing reduced temporalis muscle strength [20]. Furthermore, the occlusal contact force values in the posterior half of the dental arch were greater on the elongated side, with more extensive bite force areas and additional occlusal contact points during lateral occlusion [20, 21]. Different from the previous experiment, this experiment uses the method of evaluating the degree of occlusal surface wear in the posterior region to evaluate the force distribution in the posterior region, which is more intuitive and reproducible.
As the third molar continues to elongate, it causes occlusal interference with the distal surface of the opposing second molar. Prolonged occlusal interference results in wear facets, and such interference at the terminal end of the dental arch has widespread effects across the entire dental arch [7]. This leads to uneven occlusal loads, causing asymmetric wear across the dentition. Greater occlusal load on the tooth surface leads to more pronounced wear, magnifying the impact of occlusal interference. The acidity and alkalinity of food, as well as its hardness, also affect tooth surface wear. However, this influence is often generalized across the entire mouth, with little difference in wear values between the left and right sides.
The Smith 5-level classification remains the most widely used method for assessing tooth wear in current clinical practice [22]. While straightforward, this approach lacks precision in evaluating asymmetrical wear on the buccal and lingual aspects of individual teeth. To address this limitation, Lagan et al. introduced a quadrant-based method in which the occlusal surface is divided according to the number of cusps, and each quadrant is scored based on the extent of dentin exposure [16]. Mean and standard deviation values are then calculated to reflect both the average wear and the degree of variation across the tooth surface. This method offers enhanced reproducibility and more accurately captures localized wear patterns. Accordingly, the present study adopted Lagan’s modified scoring system, which enabled quantification of average bilateral molar wear and evaluation of intra-tooth wear dispersion, thereby identifying asymmetrical wear at the cusp level. While unilateral third molars contribute to asymmetrical wear of the tooth surface, asymmetrical wear leads to lots of clinical implications. Chen Yu et al. utilized the T-SCAN occlusal analysis system to investigate occlusal patterns in 27 patients with tooth craze lines, comparing them with a control group. Their findings confirmed a significant association between occlusal interference and the presence of craze lines, identifying asymmetrical wear as a key risk factor [23].
Consistent with these findings, the current study demonstrated that unilateral third molar elongation leads to asymmetrical occlusal wear, with more pronounced differences in cusp-level wear compared to the control group. Such discrepancies may contribute to various clinical complications, including steep cuspal morphology, tooth craze lines, dentin hypersensitivity, and occlusal trauma. In cases of unexplained sensitivity, non-carious craze lines, or occlusal dysfunction, clinicians should assess for the presence of a unilaterally elongated third molar as a potential contributing factor. Furthermore, in instances of fractured restorations, porcelain chipping, or implant failures, occlusal interference from an elongated third molar should be considered. Prior to initiating fixed prosthodontic or implant restorative procedures, extraction of the unilateral elongated third molar is recommended to eliminate occlusal imbalance and mitigate future complications.
TMDs affect approximately 34% of the global population [24], necessitating reliable diagnostic imaging of the temporomandibular joint. Arthrography, magnetic resonance imaging, and CBCT represent core modalities in clinical evaluation [25, 26]. Contrasting to radio graphs and magnetic resonance imaging, CBCT provides three-dimension imaging of osseous structures. Previous studies have identified CBCT as the modality of choice for evaluating bony components of the TMJ, enabling detection of subtle osseous changes not discernible on standard radiographs [27–29]. In the present study, bilateral CBCT scans were obtained for both groups to generate three-dimensional reconstructions and measure TMJ space dimensions for comparative analysis.
Conclusion
Unilateral elongation of the third molar was associated with asymmetrical joint space distribution and irregular posterior tooth wear. Early extraction of elongated third molars is advised to restore occlusal equilibrium and reduce the risk of related complications. The optimal time to extract the elongated third molar should be before it causes occlusal interference.
Supplementary Information
Acknowledgements
The authors extend their sincere appreciation to the first and second authors for their invaluable contributions to data collection.
Clinical trial number
Not applicable.
Authors’ contributions
guarantor of integrity of the entire study：Ying Fang，Lan Yang; study concepts：Gechang Zhang, Ying Fang; study design：Gechang Zhang, Ying Fang; definition of intellectual content：Gechang Zhang, Feifei Zeng; literature research：Gechang Zhang, Lan Yang, Min Wang; clinical studies：Gechang Zhang, Min Wang; experimental studies：Gechang Zhang, Min Wang; data acquisition：Gechang Zhang, Lan Yang, Xueyan Liu, Xinli Huang; data analysis：Gechang Zhang, Lan Yang, Min Wang; statistical analysis：Gechang Zhang, Ying Fang; manuscript preparation：Gechang Zhang, Ying Fang; manuscript editing：Gechang Zhang, Feifei Zeng, Ying Fang; manuscript review：Ying Fang, Lan Yang.
Funding
No funding, grants, or external support were received during the preparation of this manuscript.
Data availability
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Affiliated Stomatology Hospital of Guangzhou Medical University (ID: 2023015) in accordance with the Declaration of Helsinki. The research was carried out at the Guangdong Engineering Research Center of Oral Restoration and Reconstruction. All participants were informed of the experimental progress and written informed consent was obtained from all participants.
Consent for publication
Not applicable. All images presented in this manuscript (including CBCT scans and clinical photographs of tooth wear) are anonymized and do not contain any identifying patient information.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Gechang Zhang and Feifei Zeng contributed equally to this work.
Contributor Information
Lan Yang, Email: yangl1900@163.com.
Ying Fang, Email: alicesing1987@sina.com.
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Associated Data
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Supplementary Materials
Data Availability Statement
The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.