Prevalence of mandibular third molar impaction, associated pathologies, and correlation with Temporomandibular joint morphology in Spanish Population: A panoramic radiography study

doi:10.21203/rs.3.rs-4887008/v1

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Prevalence of mandibular third molar impaction, associated pathologies, and correlation with Temporomandibular joint morphology in Spanish Population: A panoramic radiography study

https://doi.org/10.21203/rs.3.rs-4887008/v1

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Background

mandibular third molar is considered as the most frequent impacted tooth in the oral cavity. Its cooccurrence could lead to some impacts including the temromandbular joint symptoms. Therefore, the present study aimed to assess the prevalence of impacted mandibular third molar (IMTM), any associated pathologies, and their correlation with temporomandibular joint (TMJ) morphology in the Spanish population.

Methods

the existing records of orthopantomography images; panoramic images (OPGs) of patients visiting the Dental Hospital of the University of Barcelona, aged 18–40 years, having IMTM, were assessed, and interpreted by experienced Oral Radiologists and retrieved from September 2021 and May 2023. OPGs were screened for the type of impaction according to Winter classification system, any associated pathologies, and shape of mandibular condyle.

Results

out of 80 OPGs, 60% were females, and the majority (53.8%) were between 18 and 28 years of age. The prevalence rate of IMTM was 86.88%, with the left side commonly involved. On both sides, oval-shaped condyle and vertical IMTM were the most common, with dental caries and bone loss being the commonly observed pathologies. 15% cases showed sclerotic changes on both sides of TMJ. A statistically non-significant difference (P > 0.05) was observed between associated pathologies and condyle shape. Vertical and mesioangular, followed by horizontally impacted mandibular third molars were observed to be the most prevalent types of impaction, resulting in a statistically non-significant association (P > 0.05) with condylar shape.

Conclusion

The pattern of IMTM in the Spanish population showed the prevalence of vertical impaction, mainly on the left side of the mandible, with a female predominance. The commonly associated pathological changes are dental caries and bone loss, revealing a significant relation with the type of impaction and condyle shape.

Third molar

Impaction

Condyle

Mandible

Temporomandibular joint

Panoramic radiograph

Teeth play an important role in maintaining the health of the oral cavity and the general well-being of an individual. When teeth fail to erupt and achieve their anatomical position and physiological functions, they are regarded as impacted teeth. According to the World Health Organization (WHO), an impacted tooth is defined as a tooth that cannot erupt in its normal occlusion because of hindrances in its eruption path in relation to factors such as overlying soft tissue, bone blocking the pathway, or any preexisting supernumerary or ankylosed teeth [1,2]. The commonly named (wisdom tooth) or third molar is the only tooth that erupts during the adolescent stage or sometimes in adulthood. The timings of third molar development are diverse, providing that the calcification takes place at the age of 5 years, and radiographic appearance is noticed by the 8-9 years of age [3]. In this regard, third molar tooth is considered the most frequently impacted tooth with reported prevalence rate of 16.7-68.6% [4]. Different theories tried to explain the fact behind the phenomena of third molars impaction; including Mendelian, phylogenetic, and orthodontic theories[5]. The prevalence and pattern of impaction of mandibular third molars (IMTM) varied with different geographical area and population [6]. Few studies have reported a female predilection regarding third molar impaction [7]. IMTM can be unilateral or bilateral. According to Winter's classification, the pattern of the impacted third molar is determined by the angle formed between the intersecting longitudinal axis of the third and second molars. Therefore, distoangular impaction ranged between (−11° to −79°), mesioangular impaction ranged between (11° to 79°), horizontal impaction ranged between (80° to 100°), and vertical impaction is ranged between (10° to −10°)] [2,3,8]. Other rare positioning of the mandibular third molar impaction such as inverted and transversal orientation have been documented in the literature[9,10]. The convention two-dimensional imaging tools including intraoral periapical radiographs and extraoral orthopantomography (OPG) remain the routinely used diagnostic methods for the visualization of the impacted mandibular third molars[11,12]. OPG display the angulation, location, and relation of impacted molars to the adjacent structures[11]. It has been found that impacted third molars can induce various pathologies or remain asymptomatic in the oral cavity[13,14]. The most frequently third molar-associated pathologies are dental caries, pericoronitis, periodontal issues, odontogenic cysts, root resorption, and tumours[15,16]. It has been advocated that these pathologies are also affected by the impacted tooth's position, eruption status, and angulation.[17,18] Various studies have been conducted globally to shed the light on the prevalence rate of impacted mandibular third molars[19,20]. However, the literature lacks studies that correlate the type of impaction with different associated pathologies and the shape of the mandibular condyle. Thus, the present study aimed to assess the prevalence of impacted mandibular third molars, associated pathologies, and their correlation with temporomandibular joint morphology in the Spanish population. This study was conducted to establish more relevant information regarding the influence of impacted teeth on the shape of the condyle. We hypothesize that the different types of impactions have an impact the TMJ changes and condyle shapes.

Study design and participants: The present retrospective study was conducted on the existing record of panoramic radiographs of patients visiting the dental Hospital of the University of Barcelona (HOUB) of both genders, belonging to the Spanish population, aged between 18–40 years, who reported between September 2021 and May 2023. The study was approved by the institutional ethical committee of HOUB (protocol number: 2022-032-1). The study is in accordance with the principles of the Declaration of Helsinki. The patient’s consent form is waived as this is an anonymous retrospective analysis of the images. Data were collected from the patients subjected to the required panoramic radiographs (for various diagnostic purposes) done in the Radiology division of Dental College in Barcelona, Spain; using simple randomization method. OPG scans were performed as advised by their concerned doctors. The patient's identity was protected using a codification system by one co-investigator. A simple randomization technique is followed to randomly retrieve the 500 OPGs. Among them, 80 images met the inclusion criteria and were subjected to the study's analysis.

Measurement methods

The OPG images were obtained using a Planmeca ProMax® X-ray unit (Planmeca Oy, 00880 Helsinki, Finland), equipped with a digital sensor called Planmeca Dimax 3. Images were taken based on the manufacturer’s recommendations at 64–70 kV and 7–14 mA, depending on the patient's gender and age. The recommended settings varied for adult females, small adults, and large adults. Well-trained doctoral students from the Oral Radiology Department conducted the analysis of the condyle shapes, type of impaction, and impaction associated pathology twice, with a two-month interval between each session. The intra-examiner reliability was calculated using the Kappa statistic. Kappa results indicated a substantial agreement of 0.68. The radiographs were screened for the shape of mandibular condyle (oval, bifid, flattened, diamond, mixed, and crooked finger types) on both the right and left sides of the mandible as described by Gupta et al.[21]. In addition, the pathological changes including dental caries, bone loss distal to the second molar of more than 3 mm measured from the cementoenamel junction to the alveolar crest, external resorption of the second molar roots and neoplastic changes were determined and correlated with the impaction type and the different shapes of the condyle. Cropped images of OPGs revealing different shapes of condyle is presented in (Fig. 1). Diagram illustration of the different Winter classification of IMTM. (Fig. 2).

Figure 1. Different types of condyle shapes based on cropped images of OPG. A). Flat shape condyle. B). Diamond shape. C). Bifid shape. D). Mixed shape (oval shaped condyle mixed with some flatness). E). Oval shape. F). Crooked-finger shape.

Criteria of inclusion

Panoramic radiographs that had impacted the mandibular third molars of patients older than 18 years were included in the study. Images revealing any surgical deformity, trauma or surgery of mandibular condyle were excluded from the study. Additionally, images of the patients younger than 18 years old, and those of low-quality and artifacts were excluded from the study.

Statistical analysis:

All data was collected in MS Excel and analyzed using SPSS 27.0 software for Windows (IBM, SPSS, Chicago, Illinois, 2022). Frequencies and percentages were computed for descriptive statistics. The chi-square statistical analysis was done for comparative analysis at the significance level of p-value < 0.05. Pearson coefficient is used for the correlation between the type of impaction, condyle shapes with respect to the sides at the significance level p-value < 0.05.

The present retrospective study revealed that out of 80 panoramic radiographs, 60% were of females and most of them (53.8%) were aged between 18-28years of age (Table 1).

Table 1

Demographic distribution of the participants. Data regarding age and gender according to number and percentage
Parameter Age		Number (n)	Percentage (%)
Age groups	> 51	14	17.5
	18–28	43	53.8
	29–39	19	23.8
	40–50	4	5.0
Gender	Female	48	60.0
Gender	Male	32	40.0

We also assessed the types of impactions associated with pathologies, condyle shape and TMJ changes on the right and left side of the mandible. We observed that on both sides, the vertical type of mandibular third molar impaction was the most common, and most of them either do not cause any pathology or a few leads to dental caries and bone loss. A maximum of 15% of cases showed sclerotic changes on both sides of TMJ. The most common shape of condyle was oval, followed by mixed. A statistically non-significant relation (P > 0.05) was observed between associated pathologies and condyle shape (Table 2).

Table 2

Type of impaction and changes on the right and left sides.
Parameters		Right side		Left side		Statistical analysis
Parameters		Number (n)	Percentage (%)	Number (n)	Percentage (%)	X²	p-value
IMTM (winter's classification)	Absent	12	15.0	9	11.3	2.229	1.067
	Buccally tilted	1	1.3	0	0
	Distoangular	1	1.3	0	0
	Horizontal	12	15.0	13	16.3
	Mesioangular	22	27.5	24	30.0
	Vertical	32	40.0	34	42.5
Associated pathologies	Bone loss	40	50.0	36	45.0	1.119	0.045*
	Bone loss and external resorption	1	1.3	1	1.3
	Dental caries	1	1.3	1	1.3
	Dental caries and bone loss	3	3.8	4	5.0
	No pathology detected	23	28.8	29	36.3
	Not applicable as tooth absence	12	15.0	9	11.3
TMJ changes	Erosion	5	6.3	5	6.3	2.889	0.078
	Flattening	9	11.3	6	7.5
	No change	53	66.3	55	68.8
	Osteophyte	1	1.3	2	2.5
	Sclerotic changes	12	15.0	12	15.0
Condyle shape	Bifid	6	7.5	7	8.8	1.610	0.051
	Crooked finger	7	8.8	7	8.8
	Diamond	5	6.3	11	13.8
	Flattened	6	7.5	8	10.0
	Mixed	18	22.5	14	17.5
	Oval	38	47.5	33	41.3
Total		80	100	80	100

The rate of prevalence of impaction was 86.88%, with the left side being the commonly involved side. Associated pathologies were observed with a prevalence rate of 54.37%, with most of them (56.25%) being observed on the right side (Table 3).

Table 3

Prevalence rate of the impaction and associated pathology. Data regarding the occurrence with respect to the corresponding side
Variable	Right side	Left side	Total prevalence rate
Prevalence Impaction	85%	88.75%	86.88%
Associated pathologies	56.25%	52.5%	54.37%

Association of types of impacted mandibular third molar was observed with different shapes of condyles on both the sides. On the right and left side, oval-shaped condyles were the most common. Vertical and mesioangular, followed by horizontally impacted mandibular third molars were observed to be the most prevalent types of impactions, providing a statistically non-significant association (P > 0.05) with condylar shape (Table no. 4).

Table 4

Occurrence of different shape of condyles with respect to the sides and type of impaction
Right side	Bifid	Crooked finger	Diamond	Flattened	Mixed	Oval	p-value
Buccally tilted (n = 1)	0	0	0	0	0	1	0.050
Distoangular (n = 1)	0	0	0	0	0	1
Horizontal (n = 12)	1	3	1	0	1	6
Mesioangular (n = 22)	0	1	0	4	6	11
Vertical (n = 32)	3	3	4	1	8	13
Left side
Buccally tilted (n = 0)	0	0	0	0	0	0	0.052
Distoangular (n = 0)	0	0	0	0	0	0
Horizontal (n = 13)	0	1	1	0	3	8
Mesioangular (n = 24)	2	1	4	3	6	8
Vertical (n = 34)	4	4	5	3	4	14

In craniofacial region, the mandibular bone occupies a very vulnerable and prominent position as the projected chin is a preferred target of trauma[22, 23]. The mandible is like an archery bow, with the strongest part (symphysis) at its centre and the weakest part (condyle) at its ends that makes susceptible to fracture[24]. Due to its position in the posterior of the jaw, a relationship exists between increased chances of mandibular fracture and impacted mandibular third molar IMTM[25]. This is explained by the fact IMTM can cause a decrease in the cross-sectional area of bone, hence resulting in increased chances of mandibular fracture at the angle or condyle [20, 26, 27]. Accordingly, assessing the impaction of mandibular molars is prudent. As mandibular third molar are the most frequently impacted tooth, its surgical management is also the most common practice in oral and maxillofacial surgery [28].

Several reasons contribute to the occurrence of the impaction such as inadequate space, abnormal positioning of the tooth, presence supernumerary tooth, ankylosis of the

deciduous or permanent tooth, obstruction of the pathways of eruption by pathological

conditions such as cysts or tumours, and external oblique line and buccinator muscle

influences [17, 29, 30]. It is also stated that The MSX1 and AXIN2 genes significantly mediate the occurrence of tooth impaction in coexistence of environmental factors and other modulating genetic expressions [31]. The present retrospective study revealed that out of 80 panoramic radiographs, 60% were females, and the majority (53.8%) were aged between 18 and 28. Like our study, Hashemipour MA et al.[2] Quek SL et al.[32] and Kumar VR et al.[6] observed female predominance, most commonly involving the age group 20 to 30. The higher prevalence rate in females is because of the varied growth patterns of males and females. When the third molar eruption begins, the growth of females usually stops, thus creating a rise in the prevalence rate of impaction [2, 6, 32]. Among males, jaw growth continues during the eruption of the third molars, thus creating enough space for the eruption of the third molar. Similarly, Adeola O et al.[3] also observed that the most common age group with IMTM was 20–29 years. The high prevalence at this young age group is related to the eruption of the third molars, usually in late adolescence and early adulthood. In contrast to our study, Genç BGÇ et al.[28] found male predominance in their study of the North Cyprus population. We observed that the vertical type of IMTM was the most common on both sides. In contrast to our study, Hashemipour MA et al.[2] found that horizontal and mesioangular types of impaction were the most common. Genç BGÇ et al.[28] found that mesioangular impaction was most common in the case of mandibular third molar teeth, whereas for maxillary arch, the most common type was vertical impaction. In accordance with our study, Bataineh AB et al.[33] and Almendros-Marqués N et al.[34] found that vertical impaction was the most common type of third molar impaction. The prevalence rate of impaction was 86.88%, with the left side being the commonly involved side. As reported in our study, Braimah RO et al.[35] found a higher prevalence rate of 65.2%. The higher prevalence of impacted molars in our study may be because our study location is urban. Eating junk food and a soft diet causes a decrease in masticatory muscle activity on chewing, which causes hindrance in the growth and development of the jaw bones based on functional adaptation. We also assessed the types of impaction, associated pathologies, condyle shape, and TMJ changes on the right and left sides of the mandible. We observed that the most common associated pathology was dental caries and bone loss. A maximum of 15% of cases showed sclerotic changes on both sides of TMJ. Associated pathologies were observed with a prevalence rate of 54.37%, with most (56.25%) on the right side. Like our study, Prajapati VK et al.[36] also observed dental caries followed by recurrent pericoronitis and periodontitis being the most common associated pathology with impacted mandibular third molar. This is because impaction can cause food impaction, thus leading to dental caries, periodontitis, and bone loss. Haddad Z et al.[37] found that distal caries was observed in 12.2% of mandibular third molar impaction cases. Our analysis used orthopantomography as the radiographic technique of choice for evaluating the impacted mandibular third molars. OPG has an estimated specificity of 96 to 98% for recognizing the radiographic signs [38]. The radiation dose of OPG is also lower than that of four different periapical views and has a higher diagnostic yield [39]. The disadvantage of OPG is that it has a lower diagnostic accuracy in detecting proximal caries. Because of this reason, there might be an underestimation of the incidence of dental caries in our study. In our study, the most common condyle shape was oval, followed by mixed. A statistically non-significant relation (P > 0.05) was observed between associated pathologies and condyle shape. An association of types of impacted mandibular third molar was observed with different shapes of condyles on both sides. On the right and left side, oval-shaped condyles were the most common. Shaikh AH et al.[40] found that the most common condylar shape was oval, followed by bird beak, crooked finger, and diamond. In our study, vertical and mesioangular, followed by horizontally impacted mandibular third molars were observed to be the most prevalent types of impaction, showing a non-statistically significant association (P > 0.05) with condylar shape. To date, we have not found any study observing the association of condyle shape with the type of mandibular impaction. Our study's findings can help us predict the chances of impacted third molars in the future by assessing the shape of condyles. Further, such associations, although not statistically significant, can help provide insight to future research in the field of dentistry, thus increasing the interest of clinicians and academicians.

Study limitations

small sample size, retrospective nature, and convenience sampling design. Thus, we advocate conducting prospective studies in the future with a larger sample size. We assessed panoramic radiographs for evaluation of impaction, but these are accompanied by various issues like missed pathologies, magnification, two-dimensional view, etc. Thus, in the future, we advocate using Cone beam computer tomography (CBCT) with three-dimensional views to assess better pathologies associated with impacted mandibular molars. Our study was based on hospital-based records, which lacked randomization. The results of our study are affected by selection bias and could not be generalized to the whole population of Spain. More precise studies are required using a randomized sample representative of the population of Spain. As we assessed dental records, there are chances of retrieving incomplete data that might cause variation in the prevalence rate. In addition, further studies concerning parallel clinical assessment of temporomandibular joint disorders is essential (TMD). Although, OPGs are not suitable to diagnose the morphology of the TMJ condyles with an acceptable validity. We overcome this limitation by analyzing only the OPG that are free of distortion and reveal optimal details. In addition, perform the analysis within two months interval and calculating Kappa which provided substantial intra-examiner agreement. Yet, our sample recruited minimal sample of OPGs without consideration of clinical symptoms, we designed the study based on the radiographic findings with the intention to incorporate the clinical manifestations and CBCT in further studies. We advocate conducting more elaborate prospective studies to assess the pattern of third molars and their association with the shape of the condyle in different regions of Spain.

Our findings provide valuable baseline data for the type, pattern, and prevalence of mandibular third molar impaction in relation to age, gender, anomalies, and condyle shape among the Spanish population. The pattern of impacted mandibular third molar in the Spanish population showed the prevalence of vertical impaction, mainly on the left side of the mandible, with female predominance. With a high prevalence rate, we observed that commonly associated pathologies are dental caries and bone loss, revealing a non-significant relation in correlation with the type of impaction and condyle shape.

Acknowledgement

We appreciate the help provided by the personnels who work at the Dental Hospital of the University of Barcelona (HOUB) for their support and assistance throughout the research process.

Authors’ contribution

HA wrote the entire manuscript. AED revised the manuscript. SEM performed language editing. XRL designed the methodology. MS conducted the statistical analysis. AA revised the language editing. JLL supervise the whole process and approved the final version of the manuscript.

Funding

The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through Small group Research Project under grant number RGP1/69/45.

Data availability

All relevant data are provided within the article.

Ethics approval and consent to participants

The study was approved by the ethical committee of the University of Barcelona Dental Hospital (HOUB) under the number 32/2022. All methods were carried out by relevant guidelines and regulations of the declaration of Helsinki.

Consent for publication

Patient consent was waived because we only reviewed the radiographic images of the patients anonymously, and there was no intervention or investigation on humans directly.

Competing interest

The authors declare no competing interest.

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No competing interests reported.

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Prevalence of mandibular third molar impaction, associated pathologies, and correlation with Temporomandibular joint morphology in Spanish Population: A panoramic radiography study

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