Management of upper third molars in Class II patients undergoing orthodontic distalization: a systematic review

To update previous findings, assess the impact of third molar presence or absence on distalization outcomes, and provide evidence-based clinical guidance in the management of upper third molars in Class II patients.

This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines and applied Participants, Exposure, Comparison, Outcomes, Study design criteria to define eligibility. A literature search across four databases was conducted, up to April 2025, limited to indexed studies. Two reviewers independently screened articles, resolving disagreements with a third reviewer. Included studies were categorized based on whether authors recommended extraction of upper third molars (eg, surgical germectomy) before distalization. Risk of bias was evaluated using the Newcastle-Ottawa Scale for nonrandomized studies and certainty of evidence was assessed using Grade of Recommendations, Assessment, Development, and Evaluation reporting system criteria.

Eleven studies met the inclusion criteria: 10 nonrandomized retrospective trials and one nonrandomized prospective trial. Authors of all studies reported a significant reduction in the upper retromolar space during distalization. Most found that absence or prior extraction of upper third molars facilitated improved bodily movement of first and second molars and reduced treatment duration.

Current evidence, though low in quality, suggests that the presence of upper third molars may hinder the efficiency of orthodontic distalization and affect the spontaneous eruption path of these teeth. Strategic third molar management may enhance treatment outcomes and should be considered in treatment planning.