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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 40-46

Prevalence of impacted teeth and their associated pathologies on panoramic films in the Saudi Population


1 International Medical Center, Jeddah, Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of Maxillofacial and Head and Neck Oncology, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Kamal Kanthan Ravikumar
International Medical Center, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijosr.ijosr_3_18

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  Abstract 


Aim: This study aimed to assess the prevalence of impacted teeth and their associated pathologies according to age, gender, site, and type of impaction in the Saudi population in the city of Jeddah using digital panoramic radiographs. Materials and Methods: A total of 2431 digital panoramic radiographs taken during the period between January 2010 and January 2017 were analyzed following exclusion criteria. Finally, a total of 2229 X-rays were considered for the study. Results: The most commonly impacted teeth were upper and lower left third mandibular molars. The most common angulation type was horizontal and the least was vertical impaction. Based on the overlying tissue covering the impacted teeth, soft-tissue impactions were the most common. There was no statistically significant outcome regarding the pathologies as cysts or tumors associated with the impacted teeth. There was a significant association between mesioangular impacted teeth and caries in the second molars. Conclusion: In our study, partial bony mesioangular impactions in level B positions were associated with significant distal caries in the second molars, whereas vertical impactions in level C positions caused increased distal bony loss and resorption which would warrant early surgical intervention in patients and also help in informing the patients on the ramifications of delaying the same. A statistically significant number of partial bony impacted third molars were carious, warranting early intervention.

Keywords: Impacted teeth, panoramic film, pathologies, Saudi population, third molars


How to cite this article:
Ravikumar KK, Jamal BT, Ageel R, Binaffif AA, Ageel B, Karkashan L, Olwi A, Natto Z. Prevalence of impacted teeth and their associated pathologies on panoramic films in the Saudi Population. Int J Soc Rehabil 2018;3:40-6

How to cite this URL:
Ravikumar KK, Jamal BT, Ageel R, Binaffif AA, Ageel B, Karkashan L, Olwi A, Natto Z. Prevalence of impacted teeth and their associated pathologies on panoramic films in the Saudi Population. Int J Soc Rehabil [serial online] 2018 [cited 2019 Jun 19];3:40-6. Available from: http://www.ijsocialrehab.com/text.asp?2018/3/2/40/259325


  Introduction Top


Impacted teeth are defined as those that are partially or completely embedded in the jawbone or mucosa after their normal eruption time (2/3rd of the root completed).[1],[2] Tooth impaction is due to physical barriers and abnormal positioning of the teeth or small jaws in comparison to tooth size.[2],[3] These issues are attributed to genetic factors; early loss of space; oral diseases such as fibrosis, trauma, tumors; and syndromes such as Gorlin–Goltz syndrome. Studies worldwide had reported that 3rd molars were the most impacted teeth in the jaw followed by maxillary canines and mandibular premolars.[2],[4] Impacted teeth are associated with pathologies such as caries, periodontal problems, resorption of adjacent teeth, distal caries on adjacent teeth, cysts, and tumors.[2],[5] Panoramic radiographs are routinely done in dental practice because they are easy to interpret and cost-effective and are a useful aid to diagnose asymptomatic impactions and pathologies before they become symptomatic. The western region is a major area in the Kingdom of Saudi Arabia; only limited studies have been done in this area, specifically in the city of Jeddah, which is one of the most populated cities in the country.[6]

This study aims to assess the prevalence of impaction and associated pathologies such as caries on impacted and adjacent teeth, cysts, and tumors according to age, gender, site, and type of impaction in the Saudi population in the city of Jeddah using digital panoramic radiographs.


  Materials And Methods Top


This retrospective study was conducted at the Dental and Maxillofacial Clinic in the International Medical Center, a tertiary care health institution in Jeddah, Saudi Arabia. The data were collected retrospectively in which 2431 digital panoramic radiographs taken during the period between January 2010 and January 2017 were analyzed.

The following inclusion criteria were considered for the study: age group of 18–80 years, both genders, good-quality digital panoramic radiograph, and Saudi nationals.

The exclusion criteria were poor-quality panoramic films, edentulous patients, third molars or teeth presenting with incomplete root formation, any major pathology or trauma of the jaws that affect the normal growth of permanent dentition such as syndromes or hereditary diseases such as craniostosis, Down's syndrome, or cleidocranial dysostosis. Using KaVo radiographic machine model OP300-1, out of 2431 radiographs, 2229 qualified our criteria. Ethical clearance was obtained from the institutional review board for the study.

The presence, location, depth, and angulation of all the impacted teeth including supernumerary teeth and their associated pathologies were noted. Teeth were considered impacted when they are not fully erupted to the supposed normal functional position in the occlusal plane. The angulation of the impacted teeth was recorded using the Winter's classification with reference to the angle formed between the intersected longitudinal axes of the impacted tooth and the adjacent second molar.[4] The angles were measured by a tool that is available in the CLINIVIEW software, USA and the types of angulation were vertical, mesioangular, horizontal, and distoangular according to the Winter's classification. Other angulations such as buccolingual, mesioinverted, distoinverted, and distohorizontal angulations were classified as “other.”[7]

Maxillary teeth were recorded as impacted when the lowest portion of the crown of the tooth was below the occlusal level of the adjacent tooth. Based on the overlying tissue above the impacted tooth, the depth of impaction was considered as follows: soft-tissue (ST) and hard-tissue impactions. In ST impaction, the maximum height of the tooth's contour is above the level of the surrounding bone and the superficial portion is covered by ST. In hard-tissue impaction, the teeth fail to erupt due to obstruction by the overlying bone and further classified as partial bony impaction (PBI) and complete bony impaction (CBI). In PBI, the superficial part of the tooth is covered only by ST, but the height of the contour is below the level of the surrounding bone. Apart from cutting the gingiva, possible bone removal behind the tooth may be required. In CBI, the tooth is completely enclosed in the bone so that, when the gingiva is reflected, the tooth cannot be seen. The following levels were considered in the depth of impaction of the teeth. Level A is not buried by bone, level B is partially buried by bone, and level C is completely buried by bone.[2],[8]

Classification of the associated pathologies with the impacted teeth included caries, widening of periodontal ligament space, loss of lamina dura, root resorption in the adjacent teeth, and increase in the follicular space of >5 mm around the impacted teeth. In addition, cyst formation or tumors associated with the impacted or adjacent teeth were recorded.


  Results Top


A total of 2431 digital panoramic radiographs were screened, of which 2229 X-ray films qualified our criteria. The age distribution was classified as Group A (18–30 years), Group B (31–50 years), and Group C (>50 years).

Age [Table 1]

  1. Comparing age and the most commonly impacted teeth, the most common impacted tooth was left mandibular third molar and its prevalence was highest in all groups
  2. Comparing age with the depth of impaction, ST impaction in Group A was 9%, whereas that of Group B was 9.8% and that of Group C was 1.2%


    • PBI in Group A was 58.8%, in Group B was 50.7%, and in Group C was 32.5%
    • CBI in Group A was 32.1%, in Group B was 39.5%, and in Group C was 66.2%


    In Groups A and B, PBIs were more compared to that in Group C which had more of CBI. The results were statistically significant (P = 0.00)

  3. Comparing age with the level of impaction, level A in Group A was 10.4%, in Group B was 13.4%, and in Group C was 1.2%


    • Level B in Group A was 56.5%, in Group B was 44.6%, and in Group C was 30%
    • Level C in Group A was 33.1%, in Group B was 42%, and in Group C was 68.8%
    • In Group A, level B impactions were more common, whereas in Group C, level C was more common. The results were not statistically significant


  4. Comparing age with angulation, in Group A, horizontal impaction was more common (41.6%), with vertical impaction being the least with 12.6%


  5. In all the age groups, the horizontal impactions were the most common. In Groups A and C, vertical impaction was the least common and in Group B, distoangular was the least common. The results were not statistically significant

  6. Comparing age with caries and associated periapical and cystic lesions with the third molars, the following were observed:


    • Group B had an increased incidence of caries in the third molars (56.2%), with the least incidence in Group A at 12.5%
    • Occurrence of periapical and cystic lesions was more common in Group B (41.4%) and least in Group C (22.4%).


    The results were not statistically significant

    • Comparing age with distal caries in the second molar, Group A had an increased occurrence of distal caries in the second molar (65.9%), with the least incidence in Group C (4.7%).


    The results were statistically significant

    • Comparing age with root resorption/bone loss in the second molar, Group C had the highest root and distal bony resorption at 16.7%. Group A had the least at 12.6%.


The results were not statistically significant.
Table 1: Age

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Gender [Table 2]
Table 2: Gender

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  • Comparing gender with the distribution of impacted teeth, both maxillary and mandibular impactions were more in females compared to males. Within females, mandibular impactions were more compared to maxillary impactions.


  • The results were not statistically significant

    1. Comparing gender with the depth of impaction, females had more PBIs with 55.7% as compared to males with 50%, and CBIs were 35.1% in females as compared to 42.1% in males.


    2. The results were not statistically significant

    3. Comparing gender with the level of impaction, level B was more common in females (50.8%) as compared to males (48%)


    4. The results were not statistically significant

    5. Comparing gender with angulation, horizontal impaction was more common with 39.5% in females and 42% in males. The lowest was vertical impaction with 12.7% in females and 12.1% in males


    6. The results were statistically significant

    7. Comparing gender with caries and associated periapical and cystic lesions with the third molars, in females, 15.4% were associated with caries compared to 12.4% in males, and 44.8% of the females were associated with periapical or cystic lesions as compared to 55.2% of males


    8. The results were not statistically significant

    9. Comparing gender with distal caries in the second molar, 66.7% of females and 33.3% of males presented with distal caries in the second molars


    10. The results were not statistically significant

    11. Comparing gender with root resorption/bony loss in the second molar, 14.4% of females presented with distal root resorption/bony loss as compared to 13.2% of males.


    Level of impaction [Table 3]
    Table 3: Level of impaction

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    1. Comparing the level of impaction with the number of each level, out of the 933 impacted teeth, 464 impactions were level B, and level A was the least with 100 impactions whereas level C was with 369


    2. The results were statistically significant

    3. Comparing the level of impaction with the angulation of third molars with each level, horizontal impactions in level B were the highest with 193 impactions and the least were vertical impactions in level A


    4. The results were statistically significant

    5. Comparing the level of impaction with caries and cysts associated with the third molars in each level, level B had the highest number of caries with 17.8% impactions and level C had the least with 9%. Out of the 13 cases with pathologies associated, 7 cases were in level C and 6 cases were in level B with no cystic pathologies in level A


    6. The results were not statistically significant

    7. Comparing the level of impaction with caries in the second molar, level B impactions presented with the largest number of distal caries in the second molar with 81 impactions and the least were with level A with 16 carious second molars. Level C had 32 cases of distal caries


    8. The results were statistically significant

    9. Comparing the level of impaction with root resorption/bony loss distal to the second molar, level C impaction caused more resorption of the second molar root and bony loss distal to the second molar with 19.6% impactions as compared to level B being 11.1% and the least being level A with 7% impactions


    The results were statistically significant.

    Angulation [Table 4]
    Table 4: Angulation

    Click here to view


    1. Comparing the angulation with caries and cysts associated with third molars,


      • Mesioangular impactions with 38.5% were associated with most pathologies, whereas vertical angulation was the least with 7.7%
      • Out of the 13 impacted mandibular third molars associated with pathologies, 5 cases were mesioangular and 4 cases were distoangular, while 3 cases were horizontal and only one case was with vertical impaction


      The results were not statistically significant

    2. Comparing the angulation with distal caries in the second molars, mesioangular impactions were the highest with 24.7% causing distal caries in the second molar followed by vertical with 21.2% and then by horizontal impaction with 7.1% and the least being vertical impactions with 8%


    3. The results were statistically significant

    4. Comparing the angulation with root resorption/bony loss distal to the second molars, vertical impaction was the highest with 18.8% followed by mesioangular (17.8%), distoangular (12.4%), and horizontal (10.4%)


    The results were statistically significant.

    Depth of impaction [Table 5]
    Table 5: Depth of impaction depending on the overlying tissue

    Click here to view


    1. Comparing the depth of impaction depending on the overlying tissues, the horizontal impaction was the highest with 50.6% seen as ST impactions
    2. Comparing the depth of impaction with caries and cysts associated with the third molars, PBIs presented with caries with greater prevalence, while the least were CBIs with 5.4%


    3. The results were statistically significant

    4. Comparing the depth of impaction with distal caries in the second molars, PBIs with 18.1% were the highest compared to CBIs with 9.1% and ST impaction with 11.4%


    5. The results were statistically significant

    6. Comparing the depth of impaction with root resorption/bony loss distal to the second molars, CBIs with 20.5% were the highest compared to PBIs with 10.8% and ST impactions with 5%.


    Most common impacted teeth [Table 6]
    Table 6: Most common impacted teeth

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    Comparing the most common impacted teeth in each jaw, in our study, the maxillary left third molar was the most commonly impacted tooth, while in the mandible, the right third molar was the most commonly impacted tooth.


      Discussion Top


    Studies worldwide report that 3rd molars are the most commonly impacted teeth in the jaw followed by maxillary canines and mandibular premolars as elicited in our study, in which left mandibular third molars were the most commonly impacted teeth.[2],[4] The age distribution in our study was as follows: Group A (18–30 years), Group B (31–50 years), and Group C (>50 years). In our study, the horizontal impactions were the most common in all the age groups in all the three groups. This finding was in contrast to a study done by George and Syed et al. which reported mesioangular as the most common impaction.[4],[9] In a study by El-Khateeb et al., the vertical impaction was the most common in the maxillary third molar and horizontal in the mandibular third molar.[10]

    PBI was more prevalent in Groups A and B and CBI was more in Group C; this was in comparison with studies done by George and El-Khateeb et al.[4],[10]

    Comparing age with the level of impactions, in Groups A and B, level B impaction was more common, whereas in Group C, level C was more common, and this is consistent with the results of El-Khateebet al.[10] When the relation between age and pathologies associated with third molar impactions was compared, Group B showed an increased incidence of caries in a third molar, periapical lesions, and cystic lesions, whereas the least incidence of caries in the third molar was in Group A and the least incidence of periapical and cystic lesions was in Group C. These results indicate a higher incidence of patients between the ages of 30 and 50 years to have pathology associated with the third molar. Furthermore, according to caries in the second molar, Group A appears to be more liable to get distal caries in the second molar with least incidence in Group C, but root resorption/bony loss in the second molar was the highest in Group C.

    In the present study, both maxillary and mandibular impactions were common in females as found in a majority of studies.[11],[12] Furthermore, mandibular PBIs in level B position were more compared to maxillary impactions in females. This may be due to the small size of maxillary and mandibular jaws in females when compared to males, and this result was compatible with studies done by Hou et al. in China and Mustafa in Abha. Saudi Arabia.[13],[14]

    According to the study by Nordenram et al.,[15] caries accounts for 15% of third molar extractions. The frequency of caries increases with age in erupted asymptomatic third molar patients with asymptomatic third molars.[16],[17] Polat et al. reported that horizontal and mesioangular impacted lower third molars had a high risk of caries development on second and third molars and a high risk of periodontal tissue damage on the adjacent teeth, whereas distoangular and vertical impactions had a high risk of bony loss at the distal aspect.[5] In the present study, mesioangular impactions had a higher incidence of caries on the third molar, and this result is in concordance with the study of Al-Anqudi et al. in Oman.[18] In this study, vertical angulation had the least risk which is in contrast to the study by Al-Anqudi in which horizontal angulation was the least.

    PBIs were the most common type presented with caries at 44%, with the least being ST impactions at 7%. Moreover, PBIs were the highest in distal caries of the second molar and root resorption of the second molar.

    In the present study, there were more horizontal impactions in level B position which increased the risk of distal caries in the second molar. Level C impactions had an increased incidence of root resorption and distal bony loss in the second molar, with level A being the least causing them.

    Out of the 13 impacted mandibular third molars associated with pathologies, five cases were mesioangular and four cases were distoangular, while three cases were horizontal and only one case was of vertical impaction. Comparing our findings with those of the literature also exhibited a rare occurrence of cystic pathologies associated with impacted teeth at a varying incidence ranging from 0.001% when a biopsy was indicated to 11% of clinically established cases.[15],[19]


      Conclusion Top


    The present study involves a considerably large number of panoramic films and 2229 X-rays to assess the pathologies associated with the impacted teeth in the western region of Jeddah based on variables such as age, gender, angulations, level of impaction, type of overlying tissue over the impacted teeth, caries, and bone loss. It helps clinicians to educate and inform patients on the risks and benefits of surgical removal of wisdom teeth and discuss the management of their associated pathologies. In the present study, partial bony mesioangular impactions in level B positions were associated with significant distal caries in the second molars, whereas vertical impactions in level C positions caused increased distal bony loss and resorption which would warrant early surgical intervention in patients and also help in informing the patients on the ramifications of delaying the same. A statistically significant number of partial bony impacted third molars were carious, warranting early intervention. Our study is a single-center study in the western region of Saudi Arabia, and further studies from other regions of Saudi Arabia could help us compare the prevalence of pathologies in Saudi population.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



     

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