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ORIGINAL ARTICLE
Ahead of print publication  

Prevalence, sociodemographics, and indications for extraction of impacted mandibular third molar in Najran, a Southern Saudi Arabian city


1 Department of Oral and Maxillofacial Surgery Specialty Regional Dental Center, Medical Village Complex, Najran, Kingdom of Saudi Arabia
2 Department of Orthodontics, International Medical Complex, Najran, Kingdom of Saudi Arabia

Date of Submission22-Apr-2020
Date of Decision30-Apr-2020
Date of Acceptance20-Aug-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Ramat Oyebunmi Braimah,
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_27_20

  Abstract 


Objectives: Third molar impaction is a common condition associated with a high standard of living. The main objective of the study was to document the prevalence of mandibular third molar impactions among the Najran populace.
Methods: This is a retrospective study reviewing computerized medical records and panoramic radiographs of patients presenting for the extraction of mandibular third molars. Ethical approval was granted from the General Directorate of Health Affairs, Ministry of Health, Najran region. Data such as demographics, indications for third molar removal, position, and pattern of third molar impaction were collected. Data were stored and analyzed using IBM SPSS software version 25 for IOS (Armonk, NY: IBM Corp).
Results: Of 6205 extractions, 1024 mandibular third molar extractions were carried out with a prevalence rate of 16.5%. There were 609 (59.5%) female and 415 (40.5%) male (F:M = 1.5:1). The age ranged from 17 to 69 years (mean ± standard deviation, 31.4 ± 9.6 years), with the majority (52.1%) in the age group of 21–30 years. One hundred and ninety-one (18.6%) of the pericoronitis cases were associated with vertical impaction, while the majority of the caries were associated with mesioangular impaction (323 [31.5%]). Mesio-angular impactions (40.8%) and Level A depth (477 [46.6%]) were the most common. Class I ramus relationship had the highest distribution (561 [54.8%]).
Conclusions: We have reported a prevalence rate of 16.5% of impacted mandibular third molar in mostly 21–30 years of age with female preponderance. Pericoronitis was the main indication for surgical extraction.

Keywords: Impaction, mandible, pericoronitis, prevalence, third molar



How to cite this URL:
Braimah RO, Ali-Alsuliman D, Agbaje HO, Alsalah Y, Sharma HK, Alsawas NM. Prevalence, sociodemographics, and indications for extraction of impacted mandibular third molar in Najran, a Southern Saudi Arabian city. Saudi J Oral Sci [Epub ahead of print] [cited 2020 Nov 25]. Available from: https://www.saudijos.org/preprintarticle.asp?id=299965




  Introduction Top


Third molar impaction is a fairly common condition in communities with a high standard of living.[1],[2] Many surveys have shown that the prevalence of this condition has attained high levels in industrialized countries of Europe and North America.[2] Figures documented in such developed countries range from 9.5% to 25%.[2] Lack of space, malposition, and other obstructions are responsible for tooth impaction. The positional changes of the third molar are due to the nature of the diet, the intensity of use of the masticatory apparatus, racial differences, and genetics.[2] Teeth that fail to attain a functional position in the dental arch may be pathological and should be considered for extraction. The documented indications for third molar extraction include pain, pericoronitis, periodontal disease, caries, and cyst formation.[3],[4] The pattern of tooth extractions reflects the oral health status, dental awareness, and dental services uptake of the population.[5] The presence of third molar impaction has been reported to be related to pathological conditions,[6],[7],[8] while surgical extraction has been reported to be associated with poor quality of life because of the various possible complications and sequelae.[9],[10]

In Nigeria, Olasoji and Odusanya[11] in a comparative study of third molar impaction in rural and urban areas of South-western Nigeria noted that subjects with one or more impacted third molars were seven times more common in the urban (22.8%) than in the rural (3.1%) area. The incidence of lower third molar impaction among urban dwellers was 15.1% compared with 1.9% among the rural dwellers in the same study.[11] Civilization and change of diet seemed to be responsible for the observed differences in the third molar impaction in the two geographical areas.[11]

In the kingdom of Saudi Arabia, several studies have documented the prevalence of third molar impaction in different regions. Haidar and Shalhoub[12] were the initial researchers that reported the prevalence of impacted third molar from the Central region of the kingdom in 1986 from 1000 patients. They reported a prevalence rate of 32.3%. Recently, Alfadil and Almajed[13] reported a prevalence of 58.3% from the Central region of the kingdom. In the Western region, Hassan[14] reported a prevalence rate of 40.6%, while in Asir province, an area in the Southern region, Syed et al.[15] reported a prevalence of 18.76%. From this trend, it showed that the prevalence was higher in the urban (Central and Eastern regions) areas as compared to the more countryside and conservative Southern region (Asir province). Najran, which is also a Southern region city is more countryside and conservative than the Asir region, however, no study has documented the prevalence of mandibular third molar impaction among the populace, hence the justification for this study. The main objective of the current study was to document the prevalence of mandibular third molar impactions among the Najran populace. Other objectives were to survey the relationship of the impacted third molars to age, gender, and angulations to the lower second molar and ramus of the mandible.


  Methods Top


This is a retrospective study reviewing computerized medical records and panoramic radiographs of all patients presenting for extraction of mandibular third molars at the Regional Specialty Dental Center, Najran, from January 2015 to December 2018. The dental center is a major referral dental specialty hospital with over 40 specialized clinics and serving the entire region with over 500,000 citizens. Ethical approval for the study was granted from the General Directorate of Health Affairs, Ministry of Health, Najran region. Remaining roots of mandibular third molars removal were excluded from the study. Data such as age, sex, indications for third molar removal, position, and pattern of third molar impaction were collected from the electronic medical records. Mandibular third molar impaction was classified according to Winter's (angulation of the impacted third molar to the second molar tooth), Pell and Gregory's (depth and ramus relationships of the impacted third molar) classifications.

Winter[16] in 1926 suggested a classification of the impacted mandibular third molar tooth based on its angular relationship to the long axis/occlusal of the second mandibular molar. He classified the different impactions as follows:

  • Mesioangular impaction
  • Vertical impaction
  • Horizontal impaction
  • Distoangular impaction.


The Pell and Gregory[17] classifications involve the assessment of the depth of impacted tooth compared to the height of the adjacent second molar. In this classification, the degree of difficulty is determined by the thickness of the overlying bone, which increases as the depth of the third molar increases. The classes include:

  • Level I – The occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar
  • Level II – The occlusal surface of the impacted tooth is between the occlusal plane and the cervical margin of the second molar
  • Level III – The impacted tooth is below the cervical margin of the second molar.


The second part of Pell and Gregory is based on the amount of the impacted tooth that is covered with the bone of the mandibular ramus. The classes include:

  • Class 1 – There is sufficient space between the ramus and the distal part of the second molar for the accommodation of the mesiodistal dimension of the third molar
  • Class 2 – The space between the second molar and ramus of the mandible is less than the mesiodistal dimension of the third molar
  • Class 3 – All or most of the third molar is in the ramus of the mandible.


Statistical analysis

Data were stored and analyzed using IBM SPSS software version 25 for IOS (Armonk, NY: IBM Corp). Descriptive statistics were generated as part of the data analysis, and Pearson Chi-Square was used to compare the relationship among the different categorical variables (sex, age group, position, depth of impaction, ramus relationships, and indication for extraction). The level of significance was set at P ≤ 0.05.


  Results Top


Out of 6205 extractions, a total of 1024 mandibular third molar extractions were carried out during the study period giving a prevalence rate of 16.5%. There were 609 (59.5%) females and 415 (40.5%) males (F:M = 1.5:1) [Table 1]. The age ranged from 17 to 69 years (mean ± standard deviation, 31.4 ± 9.6 years) with the majority (52.1%) in the age group 21–30 years [Table 2]. This attained significant statistics when age group was compared with gender of the patients (χ'2 = 73.478, df = 5, P = 0.000). Most of the cases of impacted mandibular third molar were mesioangular impactions (40.8%) followed by vertical impactions (27.2%). However, this did not attain statistically significant difference when the angulation was compared with the gender of the patients (χ'2 = 3.436, df = 3, P = 0.329) [Table 3]. One hundred and ninety-one (18.6%) of the pericoronitis cases were associated with vertical impaction, while the majority of the caries were associated with mesioangular impaction (323 [31.5%]) [Table 4]. With reference to depth of impaction, most of the cases were in Level A (477 [46.6%]) with a statistical significant difference (χ'2 = 16.347, df = 2, P = 0.000). Level C recorded the least frequency of 196 (19.1%) cases [Figure 1]. Considering ramus relationships, Class I cases had the highest distribution with 561 (54.8%) cases and attaining a statistical difference (χ'2 = 22.054, df = 2, P = 0.000) [Figure 2]. This was distantly followed by Class 3 relationship with 195 (19.0%) cases.
Table 1: Age group distribution according to gender of patients

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Table 2: Age group distribution according to angulation of mandibular third molar impaction

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Table 3: Distribution of Spatial relation of impacted mandibular third molar according to gender of patients

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Table 4: Distribution of indication for extraction of impacted mandibular third molar according to gender of patients

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Figure 1: Bar chart showing frequency of the depths of the impacted mandibular third molars

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Figure 2: Bar chart showing frequency of the ramus relationships of the impacted mandibular third molars

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  Discussion Top


The prevalence of mandibular third molar impaction in the Najran population attending the Specialty Regional Dental Center was 16.5%. Compared with reported prevalence rates in the other regions of the kingdom, it is relatively low. We opined that perhaps, the nature of the populace and conservative class of the region might have contributed to this low prevalence. In addition, the region is relatively countryside as compared with the central and western regions. This trend of dichotomy in the prevalence of impacted third molars has been reported in Nigeria between the rural and urban populace, with the latter having higher prevalence.[11] The main reason for this trend has been based on civilization and the change of diet in the two geographical areas.[11] When diet is switched to refined varieties as common with civilization and urban areas, there is a tendency for disuse atrophy of the jaw as a functional matrix which is required for jaw growth and development is lost.[18] The sequelae of this is tooth arch and tooth size discrepancy leading to crowding and impaction. Fibrous diet stimulates greater muscular activity, which in turn stimulates jaw growth leading to availability of space in the jaws for the eruption of the third molar among consumers of such diet, thereby reducing the incidence of impaction.[19] Functional matrix theory states that the growth of both maxillary and mandibular bones is dependent on the functional needs of tissues around the bone.[20] Therefore, a normal function is critical to the growth of the maxilla and mandibular.

Although there were more females than males in the current study, it did not attain statistically significant (P > 0.05). Studies have documented the same observation of no gender difference statistically of third molar impaction despite the female preponderance.[6],[14],[15],[21],[22],[23] On the contrary, Kumar et al.[24] have reported a statistically significant female preponderance from the Hail region of the kingdom. Likewise, some studies have reported a higher female predominance in white European females[14],[25] and Singapore Chinese females than males.[26]

This higher frequency in female gender has been linked with differences in growth patterns between males and females. Females have a shortened duration for growth of mandible compared to the males and the mandible ceases to grow when the third molar is just about to erupt, leading to higher impaction rates in females.[27],[28]

Bulk of the patients were in the age group of 21–30 years. This age bracket is the period where eruption and complete root of mandibular third molars should have been completed.[29] Most studies on impacted third molars are also conducted from the age of 18 years, were most of the third molars would have erupted.[14],[30],[31]

Controversies continue to exist in the literature between the commonest angulation of impacted third molar. Several studies have documented mesioangular impaction[30],[32],[33],[34],[35] as the commonest angulation, while others have reported vertical impaction.[25],[36],[37],[38] Our study has reported mesioangular impaction as the most frequent angulation among the study population. Study design might have contributed to this controversy, with variations between mandibular and maxillary impacted third molars. Furthermore, a study by Akpata,[39] that reported vertical impaction as the most frequent spatial relation performed the study in patients that presented with only pericoronitis as the indication for third molar removal. Pericoronitis has been reported to be very common in vertical impactions.[40],[41] This current also reported pericoronitis as the commonest indication for extraction. In another study, vertical impaction was observed to be more frequent, with an increase in age.[30] This has been attributed to an increase in retro-molar space with increase in age, thereby creating more space that may favor eruption of the impacted third molar.[42],[43] Additionally, third molars that remain impacted after 25 years of age may still change position afterward.[44]

Pell and Gregory[17] Level A depth of third molar impaction has previously been reported in the literature as the most frequently observed.[3],[17],[45],[46] In the current study, most of the cases were in level A (477 [46.6%]), which attained statistical significance (P = 0.000). On the contrary, other studies have reported level B to be the most common,[14],[36],[37], while Alfadi and Almajed[13] in a Central Saudi Arabian study has reported Level C to be the most common. With regard to Pell and Gregory ramus relationship of the impacted mandibular third molar, Class I position was observed as the most frequent in the current study. Our result tally that of Alfadil and Almajed[13] where Class I position was documented as the most frequent ramus relationship. However, Class II position was the most frequent in Tai[47] and Western Saudi Arabian[48] populations. These variations have been said to be related to racial differences, study population, and patient's selection criteria.[36]


  Conclusions Top


We have reported a prevalence rate of 16.5% of impacted mandibular third molar in mostly 21–30 years of age with female preponderance. Mesio-angular impaction with Level A depth and Class I ramus relationships was discovered predominantly. Pericoronitis was the main indication for surgical extraction. Level of civilization with diet modifications has been reported to contribute greatly to the prevalence of third molar impaction. It is crucial to carry out regular oral and radiographic examinations to monitor impacted the third molar since their position could change even after cessation of growth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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