Third Molars Impaction paTTern With Associated
Third Molars Impaction paTTern With Associated
Third Molars Impaction paTTern With Associated
Rosalina Intan Saputri1 ID , Dominica Dian Saraswati Sumantri1 ID , Aprianisa Obsidiany Daisy Tarigan2, Gabriela Christabel2
Clerkship Program, Faculty of Dentistry, Maranatha Christian University, Bandung, West Java, Indonesia
2
Abstrac t
Introduction: Third molars have the most cases of tooth impaction associated with oral and dental pathologies.
Assessment of third molar’s impaction pattern and related pathological condition are important for treatment
consideration.
Objectives: The present study aimed to observe the impaction pattern of third molars in West Java, Indonesian
population, and analysed the correlation with the impaction-associated pathologies.
Material and methods: Digital panoramic radiographs of 83 subjects (52 females, 31 males), with mean age
of 19.12 years, were obtained. From the sample, 313 third molars were classified according to Pell & Gregory’s and
Winter’s impaction classifications. Pathological conditions were registered from medical records and radiograph
examinations. Fisher’s exact test was applied to determine the significance of variables, and correlation and odds
ratio (OR) were calculated.
Results: Four pathological conditions were observed from the research sample, including caries, pericoronitis,
osteoma, and periapical abscess. Analysis of Pell & Gregory’s classification showed that there was significant evi-
dence of caries in class A, with correlation of 0.26 (OR: 18.53; 95% CI: 3.61-95.00%), and pericoronitis in class IIA,
with correlation of 0.31 (OR: 12.83; 95% CI: 4.38-37.60%). There was no significant pathologic conditions’ incident
related to Winter’s classification.
Conclusions: Within the research sample, there was two pathological conditions significantly associated with
Pell & Gregory’s classification, which were caries with class A and pericoronitis with class IIA. While there was no
pathologic condition associated with third molars’ angulation according to Winter’s classification. Future research
should consider clinical examination with greater third molars’ sample.
Key words: impaction, panoramic radiograph, third molar, third molar pathology.
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Rosalina Intan Saputri, Dominica Dian Saraswati Sumantri, Aprianisa Obsidiany Daisy Tarigan, Gabriela Christabel
Third molar is the last tooth to erupt, and generally rospectively from the Maranatha Dental Hospital. In-
starts erupting at the age of 18 to 20 years. There are seve clusion criterion was the presence of at least one third
ral theories about the occurrence of tooth impaction, such molar. Exclusion criteria were insufficient image quality,
as space deficiency, mechanical obstacles, and local factor developmental abnormalities visible on radiographs, and
(e.g., trauma), and systemic factor, including vitamin defi- history of developmental disease in the medical records.
ciency, malnutrition, and hormonal disorder [4]. Frequent Minimum sample size required to determine the correla-
occurrence of insufficient space of jaw arch for the third tion coefficient differed from zero, with a = 0.05, β = 0.20,
molar tooth to completely erupt occurs because the jaw and correlation coefficient (R) from previous research
arch is occupied by the other 28 fully erupted teeth [5]. on acute pericoronitis and mandibular third molar’s po-
Abnormal eruption also can occur as a result of physi- sition = 0.71, was 13 subjects [16, 17]. According to in-
cal obstacle, such as adjacent tooth, compact bone that clusion and exclusion criteria, 83 subjects (52 females,
blocked the eruption path, and redundant soft tissues [2]. 31 males) were included in the study. Patients’ identities
Other factors to cause impaction of third molar are early were anonymized, and coding was assigned to identify
physical maturation and late third molar mineralization [6]. each radiograph. Ethical clearance was obtained from
Impacted third molar are commonly associated with the Faculty of Medicine, Maranatha Christian University
several pathologic conditions. When a tooth starts to Research Ethic Committee (Number: 046/KEP/III/2021).
erupt, a narrow gap called peri-coronary gap is formed be- All third molars were observed by an independent
tween the tooth crown and the oral mucosa [7]. Impacted professional observer, and classified according to Pell
third molar often has abnormal position and angulation, & Gregory’s and Winter’s impaction classifications. Pell &
which leads to a greater gap between the third molar and Gregory classified the impaction according to the combi-
adjacent second molar. Therefore, it becomes a favourable nation of relation of third molar with (1) Occlusal sur-
spot for bacteria and accumulation of food debris that face of adjacent second molar, and (2) Space availability
form dental plaque. Due to a lack of ideal inter-proximal between adjacent second molar ramus of mandible [18]:
contact, dental plaque is difficult to clean [8, 9]. The relation of occlusal surface:
The accumulation of dental plaque plays integral role I. There is sufficient space between the ramus and the
in causing oral diseases, including dental caries or inflam- distal of the second molar for accommodation of the
mation of surrounding soft tissues, which result in peri- mesio-distal diameter of the third molar.
coronitis, tooth and root resorption, and other periodon- II. Space between the distal of the second molar and the
tal diseases [10-12]. Impacted third molars also present ramus of the mandible is less than the mesio-distal
an increased risk for cyst and tumour related with dis- diameter of the third molar.
order of development process, such as dentigerous cyst, III. All or most of the third molars are in the ramus of
odontogenic keratocyst, ameloblastoma, and malignant the mandible.
tumours, including squamous cell carcinoma and odon- Relation of space availability:
togenic myxoma; although the incidence is very low [13]. A. Highest portion of the third molar is on the same lev-
Despite the high prevalence, studies of pattern of third el with the occlusal plane of adjacent second molar.
molar impaction in Indonesian population are still lim- B. Highest portion of the third molar is between the oc-
ited. Research conducted in Manado, Indonesia showed clusal plane and the cervical line of adjacent second
that most impacted third molars occurring in maxilla molar.
and partially-impacted mesio-angular third molars had C. Highest portion of the third molar is on the level or
the highest prevalence compared with other angulations below with the cervical line of adjacent second molar.
[14, 15]. Based on various research conducted in Indone- While Winter classified the third molar impaction
sia, studies regarding pathological conditions associated based on the angulation between the long axes of third
with impacted third molars has not yet been published. molar and adjacent second molar [4, 19]:
I. Vertical position, 0o to 10o.
II. Mesio-angular position, 11o to 79o.
Objectives III. Horizontal position, 80o to 100o.
IV. Disto-angular position, –11o to –79o.
The present study aimed to observe the impaction
V. Other, 111o to –80o (including mesio-invert, disto-invert,
pattern of third molars in West Java, Indonesian popu
and disto-horizontal).
lation, and analysed the correlation with the impaction-
VI. Bucco-lingual position.
associated pathologies.
Radiographs’ measurements of third molars’ height
and angulation compared with adjacent second molars
Material and methods were calculated using IC Measure software for Windows,
version 2 (Figures 1 and 2). Pathological conditions relat-
Digital panoramic radiographs of three hundred and ed with third molar were recorded according to the diag-
thirteen molars were observed, with age range between nosis in medical records and radiographs’ examination.
16.04 and 21.68 years. Radiographs were collected ret- Fisher’s exact test was applied to determine the signifi-
Figure 1. Illustration of tracing line of the highest portion Figure 2. Illustration of third molars angulation was
of third molars (red line) in comparison with the highest calculated between axis of third molars and adjacent
occlusal plane of adjacent second molars (orange line) to second molars to determine Winter’s classification of I, II,
determine Pell & Gregory’s classification of A, B, and C III, IV, V, and VI
cance of variables. Correlation and odds ratio (OR) were Female Male
Results
Age
18
Age distribution of sample is presented in Figure 3,
with the overall mean age of 19.12 years (females: 19.02
years; males: 19.29 years). The number of third mo- 16
& Gregory’s classification, most of maxillary third molars Figure 3. Number of subjects per age category of half-year
were classified as class C (37.5%), although the distribu-
tion was considerably uniform with class A (30.92%)
and B (31.58%). Most of the mandibular third molars most frequent pathology present. While in the maxilla,
were classified as IIA (27.95%), followed by class IIIA the most frequent pathologic condition was dental caries
(19.88%) and class IIIB (15.53%). (Table 1).
For Winter’s classification, 63.16% of the maxillary The pathological conditions of each classification
third molars were classified as class I, followed by 26.32% according to Pell & Gregory are presented in Table 2.
as class IV. Majority of the mandibular third molars were There were two classifications with significant incidence
classified as class II (44.08%) and class I (39.47%), and of pathology of class A with caries and class IIA with
there was no mandibular third molar found as class VI. pericoronitis. Despite their significances, the correla-
There were 4 pathological conditions observed from tions of both condition and classes were relatively low
the sample, including caries, pericoronitis, osteoma, and (R = 0.26 for caries, and R = 0.31 for pericoronitis).
periapical abscess. Most of the pathological conditions OR of caries incidence in class A was 18.53 (95% CI:
were found in the mandible, with pericoronitis as the 3.61-95.00%), and OR of pericoronitis in class IIA was
Table 1. Number of third molars with pathologic conditions in maxilla and mandible
Pathologic conditions Number of teeth n Contingency
Maxilla Mandible coefficient**
Table 2. Number of third molars with pathologic condition in Pell & Gregory’s classification
Pathologic Pell & Gregory’s classification
condition Maxilla n Mandible n
A B C IA IB IC IIA IIB IIC IIIA IIIB IIIC
No pathology 40 48 57 145 17 10 4 33 21 4 28 23 2 142
Caries 6* 0 0 6 0 0 0 2 0 0 0 0 0 2
Pericoronitis 1 0 0 1 0 0 0 10** 0 0 4 1 0 15
Osteoma 0 0 0 0 0 0 0 0 0 0 0 1 0 1
Periapical abscess 0 0 0 0 1 0 0 0 0 0 0 0 0 1
n 47 48 57 152 18 10 4 45 21 4 32 25 2 161
*Significant caries incidence in class A compared to other class, p < 0.05.
**Pericoronitis incidence showed significant difference in class IIA compared to other class, p < 0.05.
12.83 (95% CI: 4.38-37.60%). On the contrary, there was compared with adjacent second molar (A, B, C), while
no significant pathologic condition evidenced related to mandibular third molars were classified as combination
Winter’s classification, although both caries and peri- of the depth (A, B, C) and space availability between
coronitis incidences appeared mostly in class I (Table 3). the ramus and distal of second molar for accommodation
of mesio-distal diameter of third molars (I, I, III) [18].
The depth of impacted maxillary third molar is most-
Discussion ly found below the cervical of adjacent second molar or
class C, based on Pell & Gregory’s classification. Previous
Third molar impaction has been one of the most de-
studies also found similar distribution in Brazilian, Leba-
manding cases associated with various complications,
nese, and Indian populations [22, 26, 27]. While study in
including life-threatening issues [20]. Third molar im-
Turkish population showed class B impaction as the most
paction’s positions were diverse amongst different popu common in the maxilla. The variation was possibly due to
lation due to the genetic characteristic, endogamy, and the higher age of study sample (mean age of 33.5 years),
epigenetic factors [21, 22]. These positions had proved which could affect further development of third molars.
to be related with the risk of producing infectious, non- Most of the mandibular third molars’ impaction was
infectious, or neurological pathology, which can occur in classified as class IIA in this study. Similar result de-
untreated teeth [23, 24]. Therefore, the pattern of impac- scribed Falci et al. in Brazilian population [28]. However,
tion’s position and related pathological condition could studies among another Brazilian populations by Primo
become potential parameters to predict certain third mo- et al. and Santos et al. showed different results, as most
lars, which should be prioritized to be extracted. of mandibular third molars were classified as class IB and
In agreement with previous studies, the present study IIB, respectively [25, 26]. Several studies in other popula-
showed that the mandibular third molar impaction pre tions also presented various results in majority of impact-
valence was higher than the maxillary third molars ed mandibular third molars according to Pell & Gregory’s
[2, 25, 26]. According to Pell & Gregory’s classification, classification, such as IIB in Lebanese population, IIB in
maxillary third molars were classified according to Indian population, and A in Indian and Saudi Arabian
the depth of highest portion of third molar’s position population [2, 22, 26, 29]. These variations indicated that
mandibular third molars had more diversity of develop- Shugars et al. presented that 29% of patients with as-
ment’s pattern compared with maxillary third molars. ymptomatic third molars were affected by occlusal car-
According to Winter’s classification [19], most of ies, which increased to 33% after 3-year follow-up [31].
maxillary third molars were in vertical position (class I), Despite the significant occurrence and high OR, both
and mandibular third molars were in mesio-angular correlations of pericoronitis with class IIA and caries with
position (class II) in present study. However, the distri- class A were considered low (R = 0.31 and R = 0.26, re-
bution between class I and class II in mandibular third spectively). Previous study by Leone et al. mentioned R
molars were considerably even, which were 60 and 67 of acute pericoronitis with variables of third molars’ posi-
third molars, respectively. Research from Turkey, Brazil, tions (height, encapsulation, distance of mid-ramus to distal
and Saudi Arabia also indicated highest distribution of surface of third molar, and to midline of arch) was 0.71, and
class I and class II positions. A study by Yilmaz et al. was considered as high correlation [17]. These differences
in Turkish population demonstrated that both maxillary were probably due to the smaller number of third molars
and mandibular third molars impaction was classified examined in previous study, which were 109 normal cases
as class I [25]. The majority of vertical position can be compared with 25 cases with acute pericoronitis. The pres-
found from studies done among Brazilian population by ent study had an increased number of sample (n = 313)
Al-Dajani et al. on maxillary and mandibular third mo- of third molars, with 16 cases of pericoronitis, thus declined
lars, and on Saudi Arabian population by Falci et al. on R to 0.31.
mandibular third molars [2, 28]. Studies among Leba In contrast, there was no pathologic condition that
nese population by Khouri et al. and another Brazilian was significantly associated with Winter’s third molar’s
population by Santos et al., presented variation of man- impaction classification. Therefore, it could be assumed
dibular third molars, which were mainly class II [26, 29]. that within the recent sample, the angulation of third
In the present study, amongst 313 impacted third mo- molars did not affect the risk of pathology development.
lars that were evaluated, 9.06% of third molars displayed Most of previous studies showed higher probability
pathological lesions. Because the sample was only evalu- of pericoronitis in third molars with vertical position, or
ated radiographically, symptomatic pathological condi- class I in Winter’s classification [23]. However, the angu-
tion, such as pain or limited mouth opening, could not be lation can be shifted through eruption process, which also
evaluated. Pericoronitis was the most present pathology, influences pathological condition [32, 33]. Distal caries
with mandibular third molars having significant high- in mandibular second molar was prevalent in mesio-
er proportion in comparison with the maxilla (Table 1). angular third molars, especially when third molars were
However, despite the most occurrence, contingency coeffi- partially or fully erupted [34]. Therefore, it can increase
cient of pericoronitis related to the number of third molars the risk of caries in adjacent part of the third molar.
without pathological conditions was considered as weak.
Related with the jaw location, pericoronitis also
demonstrated significant prevalence in class IIA in Pell Conclusions
& Gregory’s classification compared with other classes,
Based on this study, it was concluded that the most
with OR of 12.83 (Table 2). The condition was highly
frequent eruption pattern in the mandibular third mo-
related with a greater gap between the contact point
lars was class IIA with mesio-angular angulation, while
of second and third molars in IIA position, which led
class C with vertical angulation was more often found in
to plaque accumulation and triggered inflammation or
the maxillary third molars. The risk of mandibular third
infection [8, 30]. It was in accordance with a study of
molar with pericoronitis was greater than the maxillary
Almendros-Marqués’ et al., who reported class IIA and
third molar, and mostly occurred in class IIA. The risk
IIB as the most susceptible to pericoronitis [24]. Howev-
of caries was found in the maxillary third molars with
er, systematic review and meta-analysis by Galvão et al.
class A, although it was not the eruption pattern com-
noted that there was significant difference of pericoro-
monly found in the maxillary third molars.
nitis chance between position I and II; however, both
had higher chances comparing with position III. This
study also mentioned that position A had higher chance Funding
of pericoronitis compared with position B; although
the studies were limited [23], R = 0.31 for pericoronitis This research was funded by Maranatha Christian
in class IIA was reported as 12.83 (95% CI: 4.38-37.60%). University Internal Research Grant 2021, with decree
Although caries was not significantly present in number of 014/SK/MNJ/UKM/IX/2020.
the maxilla, the pathological condition was significantly
associated with third molars according to Pell & Grego Conflıct of interest
ry’s classification (class A), with OR = 18.53. It was ex-
pected that third molars, which erupted to the occlusal The authors declare no potential conflicts of interest
plane were more susceptible to caries, but this chance with respect to the research, authorship, and/or publica-
was not particularly in third molars [23]. Study by tion of this article.