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Prevalence of Impaction in Qassim University Community

Faraj Alotaiby*

Abstract

Aim of the study: to investigate the prevalence of impaction in Qassim University population and associated pathologic conditions. Materials and Methods: 66 individuals, 22-30 years old male working or studying in Qassim University were examined using digital panoramic x-ray and clinical examination. Results: 48% of them have at least one impacted tooth, partial anodontia encountered are 7% lower third molars followed be lower second premolar (2%) with retained their predecessors. Conclusion: since the age group is still young, preventive extraction of the impacted teeth is the way to avoid pathological conditions related to impaction as dentigerous cysts and ameloblastomas. Keywords: prevalence,impaction, mesioangular, distoangular, inferior alveolar canal.

Introduction

he eruption of permanent teeth represents a complex series of events, mostly genetically based, whereby eruptive movements of the tooth germ taking place at a predetermined time and route enable the tooth to find its antagonist at a predetermined occlusal plane. Apart from the eruption process, the successful development of permanent dentition involves the synchronized forward and lateral growth of both the maxilla and mandible, which compensates for the difference in size of the dentition in both bones. As the eruption process is so complex, it is not surprising that problems may arise, which lead to complications including tooth retardation or failure of eruption(1). The tooth that fails to erupt into the dental arch within the expected time is called impacted tooth. The tooth becomes impacted because eruption is prevented by adjacent teeth, dense overlying bone, or excessive soft tissue. Several theories are developed regarding causes of impaction, the most acceptable of which is the gradual evolutionary reduction in jaw size to accommodate the full complement of teeth in the arch. Ir-

regularity in position of the adjacent teeth causing pressure on impacted ones and long standing chronic inflammation causes severe fibrosis and dense mucosa membrane covering the impacted teeth are also considered as other causes of impaction. In addition, too prolonged retention of deciduous teeth and premature loss of deciduous teeth causing migration of adjacent teeth and loss of space in the arch for permanent teeth are also causes of teeth impaction, moreover, systemic causes as rickets, anemia, exanthematous diseases, endocrine dysfunction, cleft palate, cliedocranial dystosis, congenital syphilis, and achondroplasia (2). The most common impacted teeth are maxillary and mandibular third molars, followed by maxillary canines and mandibular premolars. The third molars are last teeth to erupt; therefore they are most likely to have inadequate space for eruption. In the anterior max-

illa, the canine tooth usually erupts after lateral incisor and first premolar. If space is inadequate to allow eruption, the canine tooth becomes impacted. In the mandible, the same situation also affects the mandibular premolars because they erupt after mandibular first molar and mandibular canine. Therefore if room for eruption is inadequate, one of the premolars, usually the second premolars, remains unerupted and becomes impacted (3). As a general rule, all impacted teeth should be removed unless removal is contraindicated. Extraction should be performed as soon as the dentist determines that the tooth is impacted. Removal of impacted teeth becomes more difficult with advancing age. The dentist should not recommend that impacted teeth be left in place until they cause difficulty. If the tooth is left in place until problems arise, the patient may experience an increased inci-

* 4th Year Student, College of Dentistry, Qassim University.

Fig.1. panoramic x-ray revealing several teeth including maxillary right canine

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dence of local tissue morbidity, loss of adjacent teeth and bone, and potential injury to adjacent vital structure. Additionally, if removal of impacted teeth deferred until they cause problems later in life, surgery is more likely to be complicated and hazardous, because the patient may have compromised systemic disease and the bone become more rigid and less elastic (3). Early removal reduces the postoperative morbidity and allows for best heeling. Younger patients tolerate the procedure better and recover more quickly and with less interference with their daily lives. Periodontal healing is better in the younger patient, because there is better and more complete regeneration of bone and reattachment of gingival tissue to the adjacent tooth. Moreover, the procedure is easier to perform in younger patients. The ideal time for removal of impacted third molars is after the roots of the teeth are one third formed and before they are two thirds formed, usually during the late teenage years between ages 16 to 18 (2,3,4,5). If impacted teeth are left in the alveolar process, it is highly probable that one or more of several problems will result. These problems include: periodontal diseases, dental caries, pericoronitis, pain of unexplained origin, root resorption, jaw fracture, and development of odontogenic cysts and tumors (3,6,7). Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease. With even minor gingivitis the causative bacteria have access to a large portion of the root surface, which results in the early formation of severe periodontitis. By removing the impacted third molars early, periodontal disease can be prevented and the likelihood of bony healing and bone fill into the area previously occupied by the crown of the third molar is increased (3,5,8) . When a third molar is impacted or partially impacted, the bacteria that cause dental caries can be exposed to the distal aspect of the second molar, as well as to the third molar. Even in situations in which no obvious communication between the mouth and the impacted third molar exists, there may be enough communication to allow for caries production (2,3). When a tooth is partially impacted with a large amount of soft tissue over the axial and occlusal surfaces, the patient frequently has one or more episodes of pericoronitis. Pericoronitis is an infection of the soft tissue around the crown of a partially impacted tooth and is caused by the normal oral flora. For most patients the bacteria and host defenses maintain a delicate balance, but host defenses cannot eliminate the bacteria. If the host defenses are compromised (e.g., during minor illnesses, such as influenza or an upper respiratory infection, or from severe fatigue), infection can occur. Thus although the impacted tooth has been present for some time without infection, if the patient experiences a mild, transient decrease in host defenses, pericoronitis may result (3,9). Although the overall incidence of odontogenic cysts and tumors around impacted teeth is not high, the overwhelming majority of pathologic conditions of the mandibular third molar are associated with unerupted teeth. It is therefore recommended that impacted teeth be removed to prevent the occurrence of cysts and tumors (3,10). Occasionally, patients come to the dentist complaining of pain in the retromolar region of the mandible for no obvious reasons. If conditions such as myofacial pain dysfunction syndrome and temporomandibular joint (TMJ) disorder are excluded and if the patient has an unerupted tooth, removal of the tooth sometimes results in resolution of the pain (2,3). All impacted teeth should be removed unless specific contraindications justify leaving them in position. When the potential benefits outweigh the potential complications and risks, the procedure should be performed. Similarly, when the risks are greater than the potential benefits, the procedure should be deferred. Contraindications for the removal of impacted teeth primarily involve the patients physical status. These include: extremes of age, compromised medical status, and probable excessive damage to adjacent structures (2,3). The most common contraindication for the removal of impacted teeth is advanced age. As patient ages the bone becomes highly calcified, therefore less flexible and less likely to bend under the forces of tooth extraction. The result is that more bone must be surgically removed to displace the tooth from its socket. Similarly, as patients age, they respond less favorably and with more postoperative sequelae. An 18-year-old patient may have 1 or 2 days of discomfort and swelling after the removal of an impacted tooth, whereas a similar procedure may result in a 4- or 5-day recovery period for a 50-year-old patient (2,3). Similar to extremes of age, compromised medical status may contraindicate the removal of an impacted tooth. Frequently, compromised medical status and advancing age go handin-hand. If the impacted tooth is asymptomatic, its surgical removal must be viewed as elective. If the patients cardiovascular or respiratory function or host defenses for combating infection are compromised or the patient has a serious acquired or congenital coagulopathy, the surgeon must consider leaving the tooth in the alveolar process. On the other hand, if the tooth becomes symptomatic, the surgeon must work carefully with the patients physician to remove the tooth with the least operative and postoperative medical sequelae. If the impacted tooth lies in an area in which its removal may seriously jeopardize adjacent nerves, teeth, or previously constructed bridges, it may be prudent to leave the tooth in place. When the dentist makes the decision not to remove a tooth, the reasons must be weighed against potential future complications. For younger patients who may suffer the sequelae of impacted teeth, it may be wise to remove the tooth while taking special measures to prevent damage to adjacent structures. However, for the older patient with no signs of impending complications and for whom the probability of such complications is low, the impacted tooth should not be removed. A classic example of such a case is the older patient with a potentially severe periodontal defect on the distal aspect of the second molar but in whom removal of the third molar would almost surely result in the loss of the second molar. In this situation the impacted tooth should not be removed (3). The literature shows that tooth impaction is a frequent phenomenon. However, there is considerable varia-

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tion in the prevalence and distribution of impacted teeth in different regions of the jaw. Factors affecting the prevalence include the selected age-group, timing of dental eruption, and the radiographic criteria for dental development and eruption. Although removal of impacted third molars is the most common oral surgical procedure, many investigators have questioned the necessity of removal for patients who are free of symptoms or associated pathologies. Such comments are based on the view that long-term retention of impacted teeth has little risk of pathological change in the tooth itself, or of adverse effects on adjacent structures (11-14) .

Aim of the study

The aims of this study were to investigate the prevalence and pattern of impacted teeth in Qassim University population, and to report the features of associated pathologies.

Subjects examination Table (1) Impacted Teeth in the study sample FDI Numbering 18 28 48 38 13 23 44 34 45 35 1 0 1 0 1 0 43 35 Total No. Percent

Materials and Methods:

Consecutive panoramic radiographs and clinical records of 66 patients from the university community who attended the Reception and Primary Care Clinic at the University Dental Hospital the cases are randomly selected. The age group for the sample was 22-30 years as the accepted view is that third molars are normally erupted by that age. The impaction is judged both clinically and radiographically by expert specialized dentists. The inter-observers result was calibrated to make sure of the results. Any partially impacted tooth will be considered impacted. The angulation was evaluated radiographically by the long axis of adjacent teeth in relation to the long axis of second molars. The collected data tabulated and analyzed using the Statistical Program for Social Sciences (SPSS).

Tooth Maxillary Third Molar Mandibular Third Molar Upper Canines Lower Premolars supernumerary teeth Total Maxillary Right Third Molar Maxillary Left Third Molar Maxillary Right Third Molar Maxillary Left Third Molar Upper Right Canine Upper Left Canine Lower First Premolar Lower Second Premolars Right Left Right Left Right Left Right Left

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25 13 27 48 21 1 1 1 2 1 2

32.0%

61.5%

2.6%

2.6%

Results

1 78

1.3% 100%

In the sample formed of 66 patients, 32 have at least one impacted tooth (as shown in fig.1), and impacted third molars were 93.5% of all impacted teeth followed by maxillary canines (2.6%) then mandibular 1st and 2nd premolars came equally (1.3% each) and finally supernumerary impacted

teeth (1.3%). Of the 78 impacted teeth, mandibular third molars were most commonly encountered (61.5%), followed by maxillary third molars (32%),

and maxillary canines (2.6%) as shown in table 1. The angulation of the impacted mandibular third molar was 43.8%

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Fig. 2-a the percentage of impaction in the sample, b- distribution of impaction in individual teeth vertical angulation, followed by mesioangulation with 35.4%, then 20.8% horizontal angulation. Most impacted maxillary third molars were vertically angulated by 84%, the remainder: mesio-angular (12%) and disto-angular (4%) as shown in tables 2 and 3. We found some patients with partial anodontia, most of them are mandibular third molar followed by lower second premolars. One patient with supernumerary tooth related to premolar region was recorded. Fig.3. OPG of patient with unformed lower second premolars (partial anodontia)

Discussion:

Fig.4. supernumerary tooth related to lower right premolars.

Fig.5. impacted lower right premolars are second common impacted teeth in the mandible since they are the last to erupt ahead of wisdom

The primary aim of this study was to investigate the frequency of impacted teeth in patients who attend our dental clinics. The present data indicate that the prevalence of tooth impaction in Qassim University population is relatively higher than those reported in other studies. Our data shows the incidence of tooth impaction to be 48.5%. To compare the prevalence found in this study with the different frequencies reported in the dental literature from other studied populations, one should consider the methodology used for detection of these anomalies as well as the clinical differences of the epidemiological studies, including sample selection, definition of impacted tooth and the age range of subjects (1). It is not easy to choose an appropriate sample to examine the frequency of impacted teeth. To determine the actual prevalence of tooth impaction, a representative and randomized sample of the general population is required. Undoubtedly, it is not straightforward to collect such information, as exposing patients to radiation for research purposes conflicts with medical ethics. The most common practical approach

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is to examine radiographs from specific populations, which will inevitably involve the risk of bias in the data analysis (1). All patients in this study were Saudi male aged between 21 and 30 years. Since almost all patients in their third decade have increased the overall prevalence of impacted teeth in other studies(12). This may reflect increased dental awareness in this group of patients, who were provided with free dental care services by the Qassim University Dental Hospital. In this study, 9% of patients have erupted third molar with impacted lower third molar. Clinically, a combination of erupted upper and impacted lower third molars requires special attention because of the risk of over eruption of unopposed upper third molars. Additional or pre-existing pericoronitis associated with the lower third molars may exacerbate the discomfort experienced by patients, unless extraction or occlusal adjustment is attempted for the upper third molars. We found that in 11% of the patients the impacted lower third molar have great approximation to the inferior alveolar canal, 29% of them were bilaterally. Taking variables techniques and types of radiographs for such cases pre-operatively is mandatory as the extraction of such teeth may expose the inferior alveolar structure inadvertently. Follicular enlargement of impacted third molars is another major concern in the literature because if such cystic changes develop, the management of the pathological lesion becomes more complicated. Our results were agreed with that reported in most research (not more than 1%). Although, in the literature, for patients older than 50 years, were more (6.7%). Thus, the risk of cystic changes associated with longterm impacted third molars should be considered as an indication for elective removal of asymptomatic impacted teeth(12). The angulation of an impacted tooth against the second molar has potential clinical implications. For mesioangular and horizontal impacted lower third molars partially exposed in the oral cavity, their occlusal surfaces form plaque accumulative crevices against the distal surfaces of the second molars. The distribution of angulation and Table (2) : Angulation of lower third molar impactions Lower Third Molars Mesio_Angular Right Disto_Angular Vertical Horizontal Mesio_Angular Left Disto_Angular Vertical Horizontal Mesio_Angular Total Disto_Angular Vertical Horizontal Direction No. 11 0 11 5 6 0 10 5 17 0 21 10 % 40.7 0% 40.7% 18.5% 28.6% 0% 47.6% 23.8% 35.4% 0% 43.8% 20.8% 48 100% 21 100% 27 100% Total No. %

Table (3) : Angulation of upper third molar impactions Upper Third Molars Mesio_Angular Right Disto_Angular Vertical Horizontal Mesio_Angular Left Disto_Angular Vertical Horizontal Mesio_Angular Total Disto_Angular Vertical Horizontal Direction No. 1 1 10 0 2 0 11 0 3 1 21 0 % 8.3% 8.3% 83.3% 0% 15.4% 0% 84.6% 0% 12% 4% 84% 0% 25 100% 13 100% 12 100% Total No. %

Fig.6. Note the approximation of root of impacted lower third molars to inferior alveolar canal

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2. Sweedan O. A., Textbook of Oral and Maxillofacial Surgery, chapter 5: Impacted Teeth, El Maiar Press, 2009: 168-225. 3. Peterson: Contemporary Oral and Maxillofacial Surgery, Chapter 9; Principles of Management of Impacted Teeth, St. Louis, Missouri: Mosby Co., 2003: 184-237. 4. Bruce RA, Frederickson GC, Small GS: Age of patients and morbidity associated with mandibular third molar surgery, J Am Dent Assoc 101:240, 1980. 5. Osborne WH, Snyder AJ, Tempel TR: Attachment levels and crevicular depths at the distal aspect of mandibular second molars following removal of adjacent third molars, J Peri- odontot 53:93, 1982. 6. Lysell L, Rohlin M: A study of indications used for removal of the mandibular third molar, Int J Oral Maxillofac Surg 17:161, 1988. 7. Nordenram A et al: Indications for surgical removal of the mandibular third molar, Swed Dent] 11:23-29, 1987. 8. Marmary J et al: Alveolar bone repair following extraction of impacted mandibular third molars, Oral Surg Oral Med Oral Pathol 61:324, 1986. 9. Leone SA, Edenfield MJ, Coehn ME: Correlation of acute pericoronitis and the position of the mandibular third molar, Oral Surg Oral Med Oral Pathol 62:245, 1986. 10. Stanley HR et al: Pathological sequelae of neglected impacted third molars, J Oral Pathol 17:113, 1988. 11. Aitasalo K, Lehtinen R, Oksala E. An orthopantomographic study of prevalen ce of impacted teeth. Int J Oral Surg 1972;1:117-20. 12. Chu FC et al., Prevalence of impacted teeth and associated pathologies-a radiographic study of the Hong Kong Chinese population, Hong Kong Med J. 2003 Jun;9(3):158-63. 13. Morris CR, Jerman AC. Panoramic radiographic survey: a study of embedded third molars. J Oral Surg 1971;29:122-5. 14. Yamaoka M, Furusawa K, Yamamoto M. Influence of adjacent teeth on impacted third molars in the upper and lower jaws. Aust Dent J 1995;40:233-5.

Fig.7. unopposed upper third molar related to recurrent pericoronitis. The tooth angulation also related to food impaction and plaque accumulation which play a major role in caries and periodontal disease of the tooth and the second molar

Fig.8. the distribution of angulation of impacted lower third molar compared with those collected by Petrson

depth of impaction in the impacted lower third molars seen in this study is not significantly different to that noted in other studies. This may be related to ethnic difference or the sample size in our research that may not be very representative to the population(12).

on the basis that such teeth, if retained, are likely to cause certain pathologic lesions. The evidence in the scientific literature on the prevalence of dentigerous cysts, mural ameloblastoma, epidermoid carcinoma and root resorption indicates that this concern is exaggerated.

Conclusion:

As the prevalence of impaction is higher compared to that reported in other scientific papers. Furthermore, our study group is young (younger than 30 years), which is the age that not contraindicates the extraction, the prophylactic removal of asymptomatic unerupted or impacted third molars constitutes a major proportion of all oral surgical procedures. Patients are advised to have this preventive surgery

Acknowledgement:

The researcher thanks Dr. Walid Samir, and Dr. Rami Elmoazenfor their valuable effort for achievement of this paper.

References:

1. Fardi A. et al., Incidence of impacted and supernumerary teeth-a radiographic study in a North Greek population, Med Oral Patol Oral Cir Bucal. 2010 Aug 15.