THIRD MOLAR IMPACTION Tooth eruption comprises the movement of teeth through the soft tissues of the jaw

and the overlying mucosa into the oral cavity (Craddock, 2004). The involved biological processes are not yet entirely elucidated, but the importance of the dental follicle has been established beyond doubt. Teeth may erupt too early, too late, not in the proper position, or not at all. In the latter event, one speaks of impaction. This is most often seen in lower 3rd molar teeth (Slootweg, 2007). FREQUENCY Third molar is also called wisdom tooth. It is the only tooth to erupt in the age of adolescence or even adults. Since they are the last teeth to erupt, they are most frequently impacted. According to Garn, mandibular third molar is an unusual tooth characterized by considerable variability in formation, timing, variation in crown and root morphology and not infrequently, by agenesis.

Studies in the past by Kramer et al states that maxillary third molar is commonly impacted (62.57%) than the mandibular third molar (47.44%). Impaction of mandibular third molar is more symptomatic and disturbs an individuals routine. Third molars are the teeth that are often congenitally missing which could be attributed to the evolutionary changes affecting the jaw and teeth size and also changes in the dietary habits (Shandu, 2005). Hellmen stated that jaws of the female stopped growing, when third molar just begin to erupt, whereas in males the growth of the jaws continues beyond the time of third molar and, hence, he put forth that impaction of third molar is common in females than in males. Craddock HL, Youngson CC (2004) Eruptive tooth movementthe current state of knowledge. Br Dent J 197:385391. Gann SM, Lewis AB, Bonne B. Third molar formation and its development course. Angle Ortho 1962;32:271-79. Kramer RM, Williams AC. The incidence of impacted teeth. A survey at Harlem hospital. Oral Surg Oral Med Oral Pathol 1970 Feb;29(2):237-41.

Hellman M. Our third molar teeth, their eruption, presence and absence. Dental Cosmos 1936;78(7):750-62.

DEFINITION Impaction is defined as completely or partially unerupted and positioned against another tooth, bone or soft tissue, so that its further eruption would be unlikely. Embedded teeth are individual teeth which are unerupted usually because of lack of eruptive force (Nevile et al, 2005). The pattern of impaction is determined by measuring the angle formed between the lines intersecting the long axis of the second and third molars. The long axis runs through the midpoints of the occlusal surface and bifurcation. The angle formed is used to interpret the mesial or distal inclination in relation to second molar. When the angle exceeded 65, impaction is considered as horizontal (Sandhu et al, 2005). The third molars that had reached the occlusal plane in relation to second molar are considered as normally erupted teeth (Ramamurthy et al, 2012). ETIOLOGY Tooth impactions can occur because of various reasons, such as: (i) mechanical obstruction in the path of eruption, which may include hard tissue abnormalities like odontomes, soft tissue conditions such as myxofibrous hyperplasia and ameloblastic fibroma; (ii) malpositioning of the tooth germ, either due to trauma or unknown reasons, leading to an abnormal path of eruption, which causes impactions due to lack of space; or (iii) primary failure of eruption of wellformed tooth may have strong genetic component or it could be an acquired condition, occurring due to a temporary alteration of the nerve activity in the region which, in turn, has an influence on the eruption process (Kapur et al, 2008). Lack of space is the major cause for abortive eruption (Ramamurthy et al, 2012). Impaction is a complication of normal eruption that is created by the host due to the commonest etiologies, like facial growth, jaw size, tooth size and dietary habits, lack of space followed by cysts or tumors overlying, trauma, reconstructive surgery, thickened overlying bone or soft tissue and the host with systemic disorders and syndromes (Navile et al, 2005). Teeth may erupt at the wrong place or not at all if local conditions interfere with the eruption pathway. Local factors: o Chronic inflammation that causes thickening of the mucosa around the teeth o Abnormal teeth position o The pressure of the neighboring teeth against tooth o Thickening of the bone surrounding the teeth

Persistence of deciduous teeth Premature teeth extraction A disease that causes bone necrosis due to inflammation or abscess caused Change in bone because of eksantem disease (diffuse eruption of the skin associated with systemic disease that is usually caused of infektion) in children o Bending of abnormal root o Ankylosis o Fusion (unification of enamel, dentin, enamel dentine, of two or more adjacent teeth resulting in abnormal structure) o Irradiation o Makrodontia o Hyperodontia General factors: o Postnatal Rickets Anemia Conginetal Syphilis TBC Endocrine disorders Malnutrition o Prenatal Heredity Micegenation o Growth Cleido cranial dystosis Oxycephali Progeria Achondroplasia

o o o o

Sitanggang, L. 2002. Research on Student Review: Hubungan Gigi Impaksi Molar Tiga Mandibula Dengan Ameloblastoma Serta Perawatannya. North Sumatera: Universitas Sumatera Utara.

SIGN AND SYMPTOMS (dilengkapi emak) Many impacted mandibular third molars remain asymptomatic for years (Polat et al., 2008) but are often surgically extracted to prevent development of future complications and pathologic conditions.

RO (dilengkapi emak)

Fig. I: Panoramic view showing inverted molar on left side (arrow).

An intra oral radiograph revealed presence of an impacted maxillary third molar in an inverted position. A panoramic radiograph was taken to study its relationship with adjacent structures (Fig.I) (Yufaraj, 2011). RELATED DISEASE Teeth may erupt at the wrong place or not at all if local conditions interfere with the eruption pathway. Usually, these are diseases of the jaw bone or the overlying soft tissues. Also, odontogenic tumours arising around the crown area of a developing teeth may hinder proper eruption. Quite often, the failure of a tooth to erupt will be the first sign of such a jaw tumour. Eruption of a tooth in an aberrant position more often is due to jaw lesions lying adjacent to the developing roots than to obstacles in the eruption pathway (Slootweg, 2007). Third molar surgery is not risk free, the complications and suffering following surgery may be considerable. Persistent pain and swelling, infection, trismus, alveolar osteitis (dry socket), nerve damage, permanent labial anesthesia, ulceration, bleeding, dento alveolar fracture, displacement of tooth, adjacent tooth injury, temporomandibular joint injury, and possible fracture of the mandible are possible post-operative complications (Mercier and Precious, 1992). In a study, persistent pain was the most common complication (14.7%) and dry socket and trismus were developed in less than 5%. Other complications such as bleeding, ulcerations and paresthesia were observed infrequently (Jaffar and Tin, 2009). In a study by Gbotolorun et al., (2007), 14.2% of the extractions had post-operative complications and dry socket was most common (53.2%). Salam and Tzm (2003) reported that removal of fully impacted molars caused complications such as pain, cysts, resorption of adjacent teeth, infection, crowding and axial changes in the position of the adjacent teeth were associated with 28.4% of impacted teeth. Blondeau and Daniel (2007) found only alveolitis

(3.6%), infection (2.2%) and paresthesia (1.1%) as complications after extraction and these low incidences was similar to our study. Several factors also associated with the occurrence of complications which include age, health of patient, gender, smoking status, use of contraceptive pills, degree of impaction, surgeons experience and the surgical technique used (Muhonen et al., 1997; Bui et al., 2003). Almendros-Marqus et al. (2006) stated that position of the impacted third molar may be associated with complications resulting from extraction. Almendros-Marqus et al. (2006) reported that extraction of mandibular third molars classified in Class IIA position had the highest complication. This is understandable because the space between the second molar and the ramus of the mandible is less than the mesiodistal diameter of the third molar resulting in a reduced space for elevation. This factor causes difficulty during removal and increases the risk of complication. Blondeau and Daniel (2007) found that the teeth at the position of Class IC, IIC and IIIC had more complications. Deeper impaction leading to greater likelihood of tissue disturbance and longer operation times, which explained the tendency for more complications than other positions (Kim et al., 2006). Impacted mandibular third molars are often associated with pericoronitis, periodontitis, cystic lesions, neoplasm, pathologic root resorption and can cause detrimental effects on adjacent tooth (Maaita and Alwrikat, 2000). Studies have shown that patients with retained impacted third molars are significantly more susceptible to mandibular angle fracture of the mandible (Fuselier et al., 2002, Meisami et al., 2002). Patients with impacted mandibular third molar may present with pain, caries, gingivitis and oral infections (McGrath et al., 2003). Adeyemo et al. (2008) found that caries and its sequelae was the major reason of extraction, followed by pericoronitis and periodontitis. In a small portion of patients, cysts and tumors occur around impacted wisdom teeth, requiring surgical extraction. Estimates of the incidence of cysts around impacted teeth vary from 0.001% to 11%, with a higher incidence in older patients, suggesting that the chance of a cyst or tumor increases the longer an impaction exists. A retrospective review of approximately 10,000 impacted teeth, suggested that the incidence of malignant tumours was 0.02% (2 cases in 9,994 teeth) (Jaffar and Tin, 2009). The greatest incidence of infections and neurological complications were observed in the extraction of third molars in vertical position (Almendros-Marqus et al., 2006). They concluded that there was a significant relationship between the degrees of impaction with non-infectious neurological complications. PREVENTION AND TREATMENT Studies suggest that third molars play at least some role Many impacted mandibular third molars remain asymptomatic for years (Polat et al.,2008) but are often surgically extracted to

prevent development of future complications and pathologic conditions. Many dental surgeons in Europe and America consider prophylactic extraction of fully impacted wisdom teeth as the ideal approach (Salam and Tzm, 2003; Adeyemo et al., 2006; Blondeau and Daniel, 2007). Many clinicians recommended removal of impacted third molars for denture construction. as no symptomatic improvement was noticed, the tooth was extracted by transalveolar method using standard surgical protocols, after explaining all due risks. The procedure was well tolerated and no significant postoperative complication was noticed.

DAPUS
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