Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2019; 0: 1–10
doi: 10.1111/adj.12716
The extraction of first, second or third permanent molar
teeth and its effect on the dentofacial complex
A Hatami,
C Dreyer
Department of Orthodontics, School of Dentistry, The University of Adelaide, Adelaide, South Australia, Australia.
ABSTRACT
The extraction of permanent molar teeth was first introduced in 1976 as a substitution for premolar extraction in cases
with mild crowding. Since then, a number of studies have investigated the effect of permanent molar extraction on
dentofacial harmony. Undertaking the procedure of molar extraction is most commonly recommended in response to
factors such as: gross caries, large restorations and root-filled teeth, along with its application in the management of
anterior open bite and reduction in crowding in facial regions. It has been indicated, however, that before undertaking
the extraction of molar teeth it is important to investigate the potential influence of the procedure on other molars, with
particular consideration of their eruption path. This is due to the doubt as to the effect of the exact molar teeth extraction and their consequences. In light of this, This review was undertaken to investigate and compare the effect of first,
second and the third molar teeth extraction and their subsequent dentofacial complex changes.
Keywords: dentofacial complex, extraction, first permanent molar, second permanent molar, third permanent molar.
Abbreviations and acronyms: CAI = condylar asymmetry index; TMD = temporal mandibular disorder; TMJ = temporomandibular
joint.
(Accepted for publication 12 August 2019.)
INTRODUCTION
Tooth extraction is an important issue related to the
management of the dentofacial complex and its symmetry, with the extraction rate in orthodontic patients
found to be about 25–80%.1–5 The loss of permanent
teeth most often occurs due to caries or for the treatment and management of periodontal disease6–9 with
molar teeth playing an important role in normal
occlusion.10,11 The first molar extraction in 1976 was
mentioned in an article by Williams, however, the
technique of extraction of permanent molar teeth as
the substitution for premolar extraction was first
introduced for the second molar by Richardson in
1996.12,13
Numerous
studies
have
indicated
various
approaches for molar teeth extraction in recent years,
however, the use of extraction is still controversial, as
there are no clear indications for the use of this
approach. The purpose of this article is to investigate
and compare the dentofacial complex changes which
© 2019 Australian Dental Association
arise from the undertaking of the first, second and
third molar extraction.
FIRST MOLAR EXTRACTION
Chronology and dimensions
The movement of a tooth from its development site in
alveolar bone to the occlusal plane is termed a tooth
eruption.14 This path of eruption is not reliant on pressure from the tooth itself and is instead considered a
genetic phenomena. The timing of the eruption of permanent teeth is specifically dependent on the loss of antecedent teeth.15–17 There are numerous factors which might
affect permanent teeth eruption and their chronology
such as hyperdontia, trauma and cysts, all of which are
pathologic conditions affecting eruption by commanding
space. Additionally, the presence of general factors could
be important in eruption including genetic influences,
gender, social and economic conditions, the geographic
region and the consumption of fluoride.18–23
1
A Hatami and C Dreyer
First evidence of calcification
Enamel completed
Eruption
Root completed
Overall length
Crown length
Root length
Crown width Mesio-Distal
Crown width Bucco-Lingual
Root to crown ratio
At birth
3–4 years
6 years
9–10 years
Mandibular first
molar (mm)
20.9
7.7
14.0 M root
13.0 D
11.4
10.2
1.83
Maxillary first
molar (mm)
20.1
7.5
12.9 MB root
12.2 DB
13.7 L
10.4
11.5
1.72
were based on endodontic and restorative treatment need.45 Practitioners prefer extraction of this
tooth to premolars because of its high rate of caries, root-fillings and its effect on relieving crowding.32,46 Bayram and colleagues showed that the
extraction of the first molar could be useful as the
space for third molar eruption is increased, the
effects of which are more favourable for upper
third molars in comparison with the lower.47
Disadvantages and contraindications of first molar
extraction
Additional studies have investigated the disadvantages
of the first molar extraction26,48. These include:
Advantages and indications of first molar extraction
Losing the first molar for any reason can be a challenge
for the developing occlusion especially in the mixed dentition stage24 as the first molar is an important tooth in
the development of normal occlusion of both arches.10 It
has been indicated that the first molar tooth is more
often exposed to caries which can lead to early extraction of the tooth25–28, however, overall the development
of caries in children and adolescents has decreased since
1980.29–31 The most common indications for the extraction of this tooth are caries, endodontic problems, and
cases of hypomineralization.32
First molar extraction advantages and indications:
(a) Management of impaction. It has been indicated
that due to the lack of space the third molar
could become impacted and that this tooth shows
the highest impaction rate of all teeth. In a study
carried out by Ay et al., it was suggested that
mandibular third molar eruption could be facilitated by mandibular first molar extraction.33
(b) Management of molar incisor hypomineralization.
This condition which is estimated to involve about
25% of European children and 3.6–19% in other
populations34–38 is defined as inadequate mineralization in molar teeth34 resulting in a painful sensation when brushing or breathing cold air in
which can require complex treatment.38,39 Jalevik
et al. evaluated 27 children with hypomineralized
teeth, and found that extraction of the first permanent molar could be beneficial. The study also
found that the patient’s permanent dentition positioning and the reduction of the space did not
cause particular concerns.40 Regardless of other
conditions restorative treatment of hypomineralized molars caused practitioners a variety of management problems.41–44
(c) First molar extraction as part of orthodontic treatment. In 2010, Ong et al. suggested first molar
extraction and its advantages and disadvantages
2
(a) Tipping of adjacent teeth towards the extraction
site;
(b) Shifting of the dental midline towards the site of
the extraction;
(c) Change in chewing habits;
(d) Periodontal and temporomandibular joint problems.
Of particular concern is the potential of the first
molar extraction to negatively impact on dentofacial
symmetry. This is defined as the similarity in shape
and volume of both sides of the face, however, the
exact equilibrium is theoretical.49–51 Caglaroglu and
colleagues demonstrated, by using postero-anterior
radiographs in 25 patients with maxillary permanent
first molar extraction, 26 mandibular permanent first
molar extraction and 30 controls, that patients who
had early molar extraction could be faced with dental
and skeletal asymmetry. This finding was also supported by Farkas and Hewitt amongst others.52,53
Halicioglu investigated bilateral mandibular first
molar extraction and its effect on asymmetry in adult
patients. In this study, the Condylar asymmetry index
(CAI), ramal asymmetry index and condylar plus ramal
asymmetry index were measured. The study found that
the CAI was increased in both cases and control groups,
however that there was no significant difference
between the groups.54,55 By considering these studies, it
can be suggested that the extraction of the first molar at
mixed dentition stage could be important in dentofacial
asymmetry but when this extraction happens in the
adult there is no evidence of asymmetry. Furthermore,
asymmetrical extractions when considered have to be
evaluated carefully to prevent the side effect of asymmetry such as midline shift, temporal mandibular disorder (TMD) and cross bite.
Timing for first molar extraction
The differences in mandibular and maxillary first
molar eruption could play an important role in
© 2019 Australian Dental Association
Molar extractions
extraction timing.56 There are limited studies on this
subject. Conway et al. in an evaluation of three cases
showed that maxillary Molar extraction results were
favourable in two children who were aged more than
11 years in comparison with one child at 8 years.57
Additionally, Jalvek’s study showed that the result of the
maxillary first molar extraction in patients older than
8 years could be more promising in comparison with
those under 8 years.40 The mandibular first molar
extraction was also investigated in studies by Conway
and Jalevik. In the Conway study, a mandibular first
molar extraction was performed in two patients aged 11
and 12 years, however, the results of the extractions
were inconclusive. However, in Jalevik’s study the
mandibular extraction in 12 patients showed favourable
results despite the differences in their age.40,57 Considering the limited number of studies there is not enough evidence to determine a definite conclusion, however,
based on current literature, it is suggested that the
extraction of the first molar is favourable in orthodontic
treatment of patients older than 8 years old. Ay et al.
noted that the early extraction of the first molar could
cause dentofacial asymmetry, premature contacts and
uncontrolled tipping.58
Other molar position changes after first molar
extraction
The loss of a permanent maxillary first molar is
commonly followed by a mesial drift of the second
(a)
(b)
Fig. 1 In this patient the first molar extraction effect on the third molar
development is illustrated. This panoramic radiograph shows third molar
development acceleration in the maxillary (a) and mandibular (b) where
extraction of the first molar has occurred.61
© 2019 Australian Dental Association
molar, which along with the extraction of the first
molar can provide a favouable space for third molar
eruption into the second molar site.47 Additionally,
the extraction of the second molar might trigger this
shift by better positioning the third molar at the
time of its eruption.59,60 Halicioglu et al. investigated permanent first molar extraction effects on the
third molar development and showed that the
extraction of the first molar can have beneficial
effect on developmental acceleration of the third
molar on the mandibular and maxillary extracted
side (Fig. 1).61 In addition, first molar extraction
can also provide a greater vertical angulation of
third molar (Table 1).33,47
Angle’s classification in first molar extraction
Angle’s classification is a common method for the
evaluation of malocclusion of teeth.62 Teo et al. investigated the Angle’s classification in patients with first
molar extraction and the position of the second molar
after 5 years. They could not show any significant
association between Angle’s classes and space closure.
Even by considering any significant relationship most
of the cases with upper first molar extraction led to
adequate space closure.59
SECOND MOLAR EXTRACTION
A permanent second molar is the tooth located distally from the first molars and mesial from the third
molars.63 The first molar tooth might be sacrificed
during orthodontic extraction26 however, the special
anatomical position of the second molar and the
outcome of extraction modalities has been the focus
of attention for some time in the Western
world.63,64 Recently, second molar extraction has
become a topic of interest and controversy among
dental professionals.65
There is discordance in the scientific literature on
the conditions of the adjacent second molar associated with the extraction of neighbouring molars.
Retrospective studies have reported relatively high
residual periodontal defects at the distal aspect of
the second molar after third molar extraction.66–69
However, some prospective studies have shown different clinical outcomes with relative periodontal
improvements.67,70,71 Studies have shown different
results of improvement, unchanged or even deterioration of periodontal status.67 Orthodontic treatment
involving the extraction of the second molar comparably takes significantly shorter time for periodontal
ligament to heal than with non-extraction methods
of treatment.72
3
A Hatami and C Dreyer
Table 1. Important studies in this field and their Intended conclusion
Author
Year
Conclusion
Yavoz
2006
Ay
2006
Jalevik
2007
Caglaroglu
2008
Bayram
2009
Teo
2013
Halicioglu
2013
Halicioglu
2014
The extraction of the first permanent molar can induce third molar
eruption in early ages
First molar extraction increases the third molar space, aids in better
development, eruption and better movement into the space. Also
increase in vertically angulated third molars
Extraction of first molar is an appropriate alternative in patients with
hypomineralization.The permanent dentition positioning and dental
development in these patients was suitable without any intervention
Early unilateral first molar extraction can lead to dental and skeletal
asymmetries
First molar extraction increases the third molar eruption space and
increases the maxillary third molar angulation more than the
mandibular
There was no statistically significant association between Angle’s
classes and space closure
Condylar asymmetry index were increased but there were no
statistical significant difference in asymmetry between these groups
The first molar extraction caused increased third molar eruption
acceleration in both maxilla and mandible
3.1 Chronology and dimensions73–75
First evidence of calcification
Enamel completed
Eruption
Root completed
Overall length
Crown length
Root length
Crown width MD
Crown width BL
Root to crown ratio
Mandibular second
molar (mm)
20.6
7.7
13.9 M root
13.0 D
10.8
9.9
1.82
2.5–3 years
7–8 years
11–13 years
14–15 years
Maxillary second
molar (mm)
20.0
7.6
12.9 MB root
12.1 DB
13.5 L
9.8
11.4
1.70
Advantages and indications of second molar
extraction
Second molar extraction has been recommended as an
orthodontic treatment option.77 The indications for
the extraction of the second molars include:
(a) Presence of severe caries.
(b) Ectopically erupted or severely rotated molars.76–79
(c) Existence of mild-to-moderate arch length deficiencies with concurrent good facial profiles.
(d) Crowding in the tuberosity area with a need to
facilitate first molar distal movement.57
(e) Relief of malocclusions developed from the eruption forces of permanent molars.80
(f) Facilitate the eruption of the third molars, thus
avoiding the need for surgical extraction.
Other advantages and considerations of second
molar extraction include:
4
Patients number
Mean age
Ref
165
15.35 2.53
122
107 patients with
unilateral mandibular
first-molar extractions
27
25.69
33
8.2
40
25 maxillary/26
mandibular/30 control
41
18.25
49
16.6
47
63
8.9
59
30 and 25 control
18.24 1.17
54
2925 panoramic
radiographs
13–20 years
61
(a) The minimal impact on the anterior profile of the
face due to the lack of visiblity.73,81,82
(b) Significantly shorter time to heal compared to the
non-extraction approach of orthodontic treatment.72
(c) Facilitation of treatment using removable appliances.
(d) Disimpaction and faster eruption of third molars.
(e) Prevention of ‘late’ incisor imbrication, fewer
‘residual’ spaces at the end of orthodontic treatment.
(f) Less likelihood of relapse.
(g) Favourable functional occlusion and mandibular
arch formation.72,83
Disadvantages and contraindications of second molar
extraction
Various authors have reported some drawbacks
regarding extraction of the second molar tooth,
including the 84
(a) Tipping and drifting of the adjacent teeth, usually
followed by missing mandibular second molars.
(b) Supraeruption of unopposed teeth.
(c) Poor gingival contours.
(d) Poor interproximal contacts.
(e) Reduced inter-radicular bone and pseudopockets.85
(f) Late lower arch crowding when extracted in the
presence of a developing third molar with insufficient space.86
(g) The development of cervicofacial subcutaneous
infections which might follow incomplete second
molar extraction.64,87
© 2019 Australian Dental Association
Molar extractions
Other disadvantages of second molar removal as
reported by several authors include:
(a) Frequent undesirable positions of erupted third
molars resulting in a second late stage of fixed
appliance therapy.
(b) That the extraction site is located far from the
area of concern in moderate-to-severe anterior
crowding.11,60,65,72,81
Timing for second molar extraction
It is believed by many orthodontists that the optimum
age for second molar extraction as a therapeutic
method is between 12 and 14 years, with the importance of the position of the third molar is equally
highlighted allowing the fill-in of space left by the second molar.80,88
The consensus of several reports is that the optimal
time of extraction of the second molar is as early as it
erupts, provided that the third molar crown is complete but before any reliable evidence of root formation. The axial alignment and angulation of the third
molar bud plays an essential role in the extraction
decision, especially if indicated at a later age.79,83,89,90
Changes in other molar position after second molar
extraction
It is noted that the loss of permanent molars is closely
followed by drift of the neighbouring teeth.91 This
shift also could be triggered by the extraction of the
second molar which might provide the third molar a
better position and hasten the time of the eruption.59,60 In relation to the drift following extraction,
Wieslander reported that the third molars usually
assume a downward and forward orientation,80 with
Richardson et al reporting slight distal movement of
the first molars and a decrease in crowding.88
It is a common belief among dental professionals
that in the long-term perspective, unopposed molars
tend to over erupt following the extraction of the
molars. Livas et al found insignificant changes in the
eruptive movement of unopposed mandibular second
molars.92 However, according to Breakspear:
(a) Path of eruption of the third molar could be
affected by the over eruption of the opposing second molar.
(b) Distal migration of the first molar when there is missing second molar and premolar crowding could also
effect path of eruption of the third molar.
(c) Following the second molar extraction a residual
space is created which is usually spontaneously
closed by distal movement of the first molars and
to some extent by spontaneous migration of the
third molars.63,80,83,93
© 2019 Australian Dental Association
A comparative study by Staggers et al., demonstrated that the maxillary and mandibular first molars
were protracted a greater amount in the second molar
compared to pre-molar extraction group. There
appeared no change in facial profile after extraction
of second-molars.83 In another study, the maxillary
first molars were found to have moved distally an
average of 1.2 mm following the maxillary second
molar extraction.72,80,94,95
THIRD MOLAR EXTRACTION
The third molar tooth (M3) is the last to appear and
is the most variable tooth affected by morphology,
eruption period and oligodontia/hypodontia.96 The
M3 is of interest to scientists when estimating the
chronological age of youngsters, to assess development, to select treatment, to establish diagnosis and
to resolve legal issues and immigration.97
Wisdom teeth are the most likely to undergo impaction
(incomplete eruption in the presence of a fully grown
root), which occurs when there is inadequate space in the
mouth, if there is an impediment by another tooth or if the
tooth has developed in an abnormal position. The
impacted tooth is generally trouble free and covered
totally or partially by soft tissue, bone or a combination of
the two.98 The development of the M3 is not without risks,
however, with Mortazavi et al.99 finding with their systematic review an association between an impacted third
molar and 10 different types of cysts and tumours.
Chronology and dimensions
The chronology of M3 varies widely across races but
generally it is found that females experience M3 development earlier than their male counterpart. The earliest
chronology of human dentition by Schour and Massler,
that is modified from Kronfeld’s table, provides an estimate of M3 chronology with maxillary dentition in the
lead. The M3 is similar to second molar being heartshaped but has a smaller crown and shorter root compared to the second molar tooth.100
First evidence of calcification
Enamel completed
Eruption
Root completed
Overall length
Crown length
Root length
Crown width MD
Crown width BL
Root to crown ratio
Mandibular third
molar (mm)
18.2
7.5
11.8 M root
10.8 D
11.3
10.1
1.57
7–9 years
12–16 years
17–21 years
18–25 years
Maxillary third
molar (mm)
17.5
7.2
10.8 MB root
10.1 DB
11.2 L
9.2
10.4
1.49
5
A Hatami and C Dreyer
The development and eruption of the third molar is
enigmatic in orthodontics, especially the mandibular
third molar.101 It’s been indicated that the early eruption of the M3 is associated with the angulation of
the developing third molar, mandibular growth and
the extraction of other teeth in the erupting
area.101,102
The eruption of M3, like other permanent teeth, is
dependent on a number of factors, including:
(a) Genetic diseases such as Amelogenesis Imperfecta, Down syndrome, Neurofibromatosis etc.
(b) Gender.
(c) Socioeconomic status (conflicting data on higher
vs. lower socioeconomic status).103
(d) Nutrition (malnutrition extending into early
adulthood delayed dental eruption).
(e) Systemic diseases (renal failure, anaemia and vitamin D-resistant rickets104).
Advantages and indications of third molar extraction
Despite its common use, the surgical removal, and the
timing of the surgical removal, of asymptomatic M3
as prophylaxis to prevent related health complications
is a controversial topic among health practitioners as
well as public and health insurance companies103,105.
As concluded by Costa et al. in their systematic
review the notion of M3 extraction as a prophylaxis
is null and void due to lack of sufficient evidence.106
However, a number of benefits exist for M3 extraction and studies have unanimously pointed to an earlier age of extraction to correlate favourably with
lesser morbidity.107 The circumstances remaining in
which extraction of the M3 is indicated, include:
(a) Impaction associated with dental caries (intractable carious lesion).
(b) Periodontal defects close to the preceding
molar.108
(c) Pericoronitis.
(d) Odontogenic cyst.109
(e) Dental tumours.105
(f) Prophylactic removal of impacted M3 is also indicated for root resorption, crowding of lower incisors and damage to the adjacent tooth.98
The M3 also plays a role as a method for evaluating a
young adult age. Chronological evidence from all other
bony tissues has been completed by the mid-adolescence,
with the M3 having the benefit of its phase of crown-root
mineralization able to be easily surveyed in a non-invasive
manner from a dental radiograph. This technique is also
useful in determining age in forensic science96 as well as in
the evaluation of dental age to provide a vital way of monitoring whether adolescents are developing sequentially.97
Dental surgeons use an appraisal of M3 mineralization to
plan autologous transplant in replacing undesirable first or
second molars.109
Disadvantages of third molar extraction
A number of changes post third molar extraction have
been observed.
(a) Increase in probing depth on the distobuccal
aspect of the second molars and a reduction in
attachment level after surgical removal of
impacted mandibular third molar.110
(b) No appreciable gain in alveolar bone height after
removal of the impacted M3 of second molars
with distal bone loss due to M3 impaction.111
The extraction of M3 is a topic of ongoing controversy.112 One of ten patients after surgical removal
experience associated complications that include;
intense pain, swelling, haemorrhage, infection, alveolar osteitis, haematoma, lockjaw105, alveolar nerve
injury113, oroantral communication, incomplete root
removal, delayed healing, infected subperiosteal hematoma and bony spicule.114 Although rare, 5 in 1000
patients over 25 years of age experience mandibular
angle fracture after M3 extraction.108
Patients commonly experience anxiety with the
removal of M3, which has a significant impact on the
outcome of the surgery due to the disturbed emotional
state of the patient.115 Kim and colleagues have
Table 2. Indications, disadvantages and proposed timing for extraction of molar teeth
Tooth/condition
Indications
Disadvantages
Changes in
other molar
position
6
First molar
Second molar
Third molar
Caries, endodontic problems,
hypomineralization
Shifting of the dental midline,
change in chewing habits,
periodontal problems,
temporomandibular joint
problems
Help in mandibular third
molar eruption
Caries, ectopically eruption, severely rotated,
orthodontic treatment
Drifting of the adjacent teeth, supraeruption of
unopposed teeth, poor gingival contours, poor
interproximal contacts, reduced inter-radicular
bone, pseudopockets
Caries, periodontal defects, pericoronitis,
odontogenic cyst, dental tumours
One of 10 patients faced with intense
pain, swelling, haemorrhage, alveolar
osteitis, haematoma, lockjaw, alveolar
nerve injury
Relieve malocclusions, facilitate eruption of the
third molars, faster eruption of third molars,
maxillary first molars could have move
distally
Relieve crowding of lower incisors
© 2019 Australian Dental Association
Molar extractions
demonstrated a significant reduction in intraoperative
anxiety of the patients in presence of their music of
choice.116 Patients appreciated having a separate consultation prior to surgical visit for M3 extraction but
it has no corralation to overal anxiety outcome.117
Timing for a third molar extraction
There is a paucity of literature on the timing for the
M3 extraction. In general, dental professionals agree
that third molars should be removed whenever there
is evidence that predicts:
(a) Cavities that cannot be restored
(b) Severe periodontal disease
(c) Infections
(d) Tumours
(e) Cysts, and/or
(f) Damage to neighbouring teeth.
In terms of tooth survival to extraction among wisdom teeth in the maxillary or mandibular arch, the
difference is insignificant but upper M3 survival time
to extraction carries the least prognosis.118 The prophylactic M3 extraction at younger age has a more
positive prognosis.107
Changes in other molar position after third molar
extraction
In patients with second molar extraction, usually the
lower third molar erupts in an acceptable position.86
Richardson et al. recommended that the presence of
the third molar could be a cause of crowding in lower
arch during the post-adolescent period.119 However,
there is no conclusive evidence to show the role of
M3 on anterior teeth crowding. Previous studies have
pointed out that molar distalization and rotation is
unaffected by wisdom teeth eruption.
After second molar extraction, M3 usually assumes
a downward and forward orientation.80 Bayram and
co-workers stated that prophylactic extraction of the
first molar provides adequate space for M3 eruption
and results in better angulation of maxillary M3 compared to the mandibular. This also decreases the
chance of impaction of M3s.120 In another study, it
was concluded that first molar extraction helps M3
occupy an optimal position but suggested if the
extraction was carried out too early, this could lead
to uncontrolled tipping of neighbouring teeth into the
extraction space.121,122
CONCLUSION
This study was carried out to evaluate dentofacial
complex changes in first, second and third molar teeth
extraction. A number of studies were included as part
© 2019 Australian Dental Association
of this review, most of which indicate that undertaking the extraction of the first, second and third molars
must involve a number of considerations. These considerations include and are not limited to;
(a) management of impaction
(b) molar pathologies such as gross caries, dentigerous cyst etc
(c) severe hypomineralization
(d) age of patient
(e) asymmetry and malocclusion
(f) molar teeth crowding
(g) Periodontal and TMJ problems
There are some circumstances in which the indications for molar extraction are clear, such as when
there is the presence of caries affecting the teeth.
However, the studies regarding timing of planned
extractions are limited and conclusions drawn
require further investigation. When planning for
extractions the known disadvantages do need to be
considered, such as alvelolar nerve injury, intense
pain, swelling and infection, unfavourable shifting of
adjacent teeth, change in occlusion, TMJ problems.
When extraction is planned for first, second or third
molars, the patients’ age and the optimum timing
for the extraction needs to be carefully considered.
This study suggests that the approach to dental
molar extraction must include the careful consideration of the effects of the extracted molar on other
molars, the faciodental complex and its symmetry
(Table 2).
CONFLICTS OF INTEREST
The authors disclose no conflicts of interest. This
research has not received any funding. All authors
have viewed and agreed to the submission.
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Address for correspondence:
Amir Hatami
38 James Street
Mount Gambier
SA 5290
Australia
Email: amh2005@gmail.com
© 2019 Australian Dental Association