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Assessment of Third Molar Impaction Pattern and Associated Clinical Symptoms in a Central Anatolian Turkish Population

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Assessment of Third Molar Impaction Pattern and Associated Clinical Symptoms in a Central Anatolian Turkish Population Original Paper Med Princ Pract 2016;25:169–175 Received: March 24, 2015 DOI: 10.1159/000442416 Accepted: November 12, 2015 Published online: November 13, 2015 Assessment of Third Molar Impaction Pattern and Associated Clinical Symptoms in a Central Anatolian Turkish Population a a a b Selmi Yilmaz Mehmet Zahit Adisen Melda Misirlioglu Serap Yorubulut a b Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, and Department of Statistics, Faculty of Science and Letters, Kırıkkale University, Kırıkkale, Turkey Key Words 705 patients (335 males, 370 females), pericoronitis was more Third molar impaction · Winter’s classification · Pain · prevalent in males (101; 30%) and usually related to lower third Pericoronitis · Turkish population molars (236; 22%). The retromolar space was significantly smaller in females (p < 0.05). Moreover, there was a significant difference in retromolar space for the area of jaw (maxillary: Abstract 11.3 mm; mandibular: 14.2 mm) and impaction level (A: 14.7 Objectives: The purpose of this study was to assess the pattern mm; B: 11.1 mm; C: 10.3 mm; p < 0.05). Conclusion: The pattern of third molar impaction and associated symptoms in a Central of third molar impaction in a Central Anatolian Turkish popula- Anatolian Turkish population. Material and Methods: A total tion was characterized by a high prevalence rate of level C im- of 2,133 impacted third molar teeth of 705 panoramic radio- paction with vertical position. Pain and pericoronitis were the graphs were reviewed. The positions of impacted third molar most common symptoms usually associated with level A im- teeth on the panoramic radiographs were documented ac- paction and vertical position. © 2015 S. Karger AG, Basel cording to the classifications of Pell and Gregory and of Winter. The presence of related symptoms including pain, pericoroni- tis, lymphadenopathy and trismus was noted for every pa- tient. Distributions of obtained values were compared using Introduction the Pearson χ 2 test. Nonparametric values were analyzed us- ing the Mann-Whitney U test and Kruskal-Wallis test. Results: Tooth impaction is a pathological situation in which a The mean age of the subjects was 30.58 ± 11.98 years (range: tooth cannot or will not erupt into its normal functioning 19–73); in a review of the 2,133 impacted third molar teeth, the position [1] . In human dentition, the third molars have most common angulation of impaction in both maxillaries the highest impaction rate of all teeth [1] . The major fac- was vertical (1,177; 55%). Level B impaction was the most com- tors related to tooth impaction are lack of space, limited mon in the maxilla (425/1,037; 39%), while level C impaction skeletal growth, increased crown size and late maturation was the most common in the mandible (635/1,096; 61%). Pain of the third molars [2] . Although impacted third molars (272/705; 39%) and pericoronitis (188/705; 27%) were found may remain symptom free indefinitely, they could give to be the most common complications of impaction. Among cause for various symptoms and pathologies, such as © 2015 S. Karger AG, Basel Dr. Mehmet Zahit Adısen 1011–7571/15/0252–0169$39.50/0 Department of Oral and Maxillofacial Radiology Faculty of Dentistry, Kırıkkale University E-Mail [email protected] Th is is an Open Access article licensed under the terms of the TR–71450 Kırıkkale (Turkey) www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un- E-Mail m_zahit @ hotmail.com ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu- tion permitted for non-commercial purposes only. Downloaded by: 156.213.67.206 - 6/21/2016 1:39:57 PM Level A Level B Level C Color version available online Fig. 1. Pell and Gregory classification. Level A: the occlusal plane of margin of the second molar (the highest portion of the impacted the impacted tooth is at the same level as the occlusal plane of the third molar is below the occlusal plane but above the cervical line of second molar (the highest portion of the impacted third molar is on the second molar); level C: the impacted tooth is below the cervical a level with or above the occlusal plane); level B: the occlusal plane margin of the second molar (the highest portion of the impacted of the impacted tooth is between the occlusal plane and the cervical third molar is below the cervical line of the second molar). 10Vertical –10 Mesioangular Distoangular Color version available online –80 80 Horizontal Fig. 2. Winter’s classification. Vertical im- paction: the long axis of the third molar is parallel to the long axis of the second molar 100 (from 10 to –10°); mesioangular impac- tion: the impacted tooth is tilted toward the second molar in a mesial direction (from 11 to 79°); horizontal impaction: the long axis of the third molar is horizontal (from 80 to 100°); distoangular impaction: the long axis of the third molar is angled dis- 180 tally/posteriorly away from the second mo- lar (from –11 to –79°); others (from 101 to –80°). pericoronitis, pain, swelling, distal caries, bone loss, root portant variations which anticipate difficulty of extrac- resorption of adjacent teeth, odontogenic cysts and tu- tion. Several methods have been used to classify impac- mors [3] . It is considered that the occurrence of pathol- tion [4] . This classification is based on many factors, ogy resulting from impaction has a multifactorial origin which are the level of impaction, the angulation of the [4] . Eruption status, position and angulation have an im- third molars and the relationship to the anterior border pact on these symptoms [4] . The decision whether or not of the ramus. The depth or level of maxillary and man- to remove a mandibular third molar is probably one of dibular third molars can be classified using the Pell and the most frequent treatment decisions in the dental pro- Gregory classification system, where the impacted teeth fession [3, 5, 6] . Hashemipour et al. [7] had noted that the are assessed according to their relationship to the occlusal anatomical position of impacted third molars shows im- surface of the adjacent second molar [2] . 170 Med Princ Pract 2016;25:169–175 Yilmaz/Adisen/Misirlioglu/Yorubulut DOI: 10.1159/000442416 Downloaded by: 156.213.67.206 - 6/21/2016 1:39:57 PM proved by the administration of the Faculty of Dentistry. Exclusion criteria were records of patients aged <19 years with any patho- logical dentoalveolar condition, any craniofacial anomaly or syn- drome such as Down syndrome, cleidocranial dysostosis or the presence of incomplete records or poor-quality orthopantomo- grams, incomplete root formation of third molars or absence of adjacent second molars, a history of any dental extraction or orth- Color version available online odontic treatment. When reviewing panoramic radiographs, clin- ical records of patients were also examined, and related symptoms including pain, pericoronitis, lymphadenopathy (LAP) and tris- mus were noted for every patient. All impacted third molar teeth on panoramic radiographs were reviewed by a single examiner (S.Y.) using a Cliniview 10.0.2 (Instrumentarium, Tuusula, Fin- land) X-ray viewer to determine the levels of eruption and angula- tions. In order to minimize the risk of false assessments caused by fatigue, no more than 50 radiographs were evaluated at a time. The depth of impacted lower third molars in relation to the occlusal plane was recorded according to the classification of Pell and Greg- ory ( fig. 1 ). The angulation of an impacted third molar was docu- mented based on Winter’s classification with reference to the angle formed between the intersected longitudinal axes of the second and third molars ( fig. 2 ). The distance from the ramus to the distal surface of the second molar (retromolar space) was also measured ( fig. 3 ). Distributions of obtained values were compared using a Pear- son χ 2 test, using the Statistical Package for the Social Sciences 22 software. Distribution of retromolar space was tested for normal- ity using Kolmogorov-Smirnov and Shapiro-Wilk tests. When the retromolar space was not found to be normally distributed (p < 0.05), the Mann-Whitney U test was used to compare 2-group variables. The Kruskal-Wallis test and pairwise comparisons were used to compare 3-group variables. One hundred panoramic ra- Fig. 3. Retromolar space measurements on panoramic radiogra- diographs were re-evaluated after an interval of 1 week to measure phy (red double-headed arrows; colors in the online version only): intraexaminer error. The Cohen kappa coefficient was found to be a = line from the anterior limit of the mandibular ramus; b = line 91%. from the posterior limit of the maxillary second molar; c = line from the posterior limit of the mandibular second molar. Results In previous studies on the Turkish population, the im- pacted molars were examined retrospectively using only Of the 705 patients (mean age: 30.58 ± 11.98 years, radiological findings that included caries, bone loss and range: 19–73) with at least 1 impacted third molar tooth, periodontal damage [3] , or the clinical symptoms were 335 (47.5%) were males and 370 (52.5%) were females; evaluated only by comparing the status of eruption [8] . the difference was not statistically significant (p = 0.187). Hence, the aim of this study was to assess the third molar From the 705 patients, a total of 2,133 impacted third impaction pattern comprehensively by examining the molar teeth was examined – maxilla: 1,037 (49%) and status of eruption and angulation on panoramic radio- mandible: 1,096 (51%) –, and the difference was not sta- graphs and relating them to the associated clinical symp- tistically significant either (p = 0.201).
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