Content uploaded by Emad Hammody Abdulla
Author content
All content in this area was uploaded by Emad Hammody Abdulla on Feb 27, 2020
Content may be subject to copyright.
Tikrit Journal for Dental Sciences 4 (2016) 50-62
50
Impacted wisdom teeth, prevalence, pattern of impaction,
complications and indication for extraction: A pilot clinic
study in Iraqi population
Labeed Sami Hasan. (1)
Firas Taha Ahmad. (2)
Emad Hammody Abdullah. (3)
_____________________________
(1) Lec., Tikrit University, College of dentistry, Basic Science/ Microbiology department.
(2) Maxillofacial specialist Ghazi all Hariri hospital for special surgery.
(3) Lec., Tikrit University, College of dentistry, Basic Science/ Microbiology department.
Key words impaction
pattern,
prevalence,
complications
and indications
Abstract
Introduction The third molars are the most frequently impacted
teeth in the human oral cavity .The unerupted teeth are not, in
themselves, pathological lesion but may induce pathology.
Impaction can be present in different patterns and levels. Decision
of removal or retention of impacted tooth is a matter of debate .
Aim The aim of the present study was to evaluate the prevalence
of impaction, angular position of impacted wisdom , level of
impaction, agenesis and the indications for extraction. Materials
and Methods A sample of 880 patients( 498 males and 382
females ) with age range between 18 to 40 years old with the
mean of 28.8 . The study took place in the hospital of surgical
specialization in which all patients were evaluated clinically and
radiographically by OPG . Of 880 patients 411pstients showed
impaction of at least one tooth (table 3) .The total number of
impacted teeth in the sample were 1100 and 57 missing teeth
(table 4). Result Among 880 patients , 411 (46.7%) patients
showed impaction of at least one tooth , the total number of
impaction was 1100 wisdom teeth . of which 428 ( 38.9%) were in
the maxilla and 672 (61.09%) were in the mandible. The most
prevalent angular position was vertical angular (59.81%) followed
by mesioangular (18.45%). Concerning level of impaction , Level
C was the most prevalent in maxilla and mandible . Agenesis of
third molar was seen in 57 teeth (1.61%). Of 1100 impacted third
molar ,663 were subjected to surgical removal .The most common
reasons ”indications” for patient referral to our surgical
department were orthodontic reasons followed by pericoronitis,
while the lowest was fracture mandible. Conclusion impaction
pattern , the mandibular impaction is more prevalent than maxilla
with vertical impaction is the commonest followed by
mesioangular impaction while the inverted impaction is negligible.
Level C impaction is the most common in both maxilla and
mandible. Concerning the indication for extraction , the most
common indication was orthodontic followed by pericoronits ,
caries with the lowest prevalent were mandibular fracture and
lesions even when the lesion represent the absolute indication for
extraction. Oral surgeon should build his decision to extract or not
extract third molars on the most canonical scientific guidelines and
what is best for each individual case.
62-05 )2016( 4….Impacted wisdom teeth
51
Introduction
The mandibular third molars are the
most frequently impacted teeth in the
human body (1). Impaction can be defined
as the tooth that fails to erupt into a
proper, functional position in the dental
arch within the expected time (2).Impacted
or unerupted teeth are not, in themselves,
pathological (Brickley et al 1995, I) but
the impaction may increase the risk of
disease, particularly when oral hygiene is
poor (SIGN 43, 2000).(3,4).
The prevalence of impaction range
between 15.2-35% among the
studies(5,6,7,8).
Concerning Pattern of impaction , the
Pell and Gregory proposed a classification
system which based on the depth or level
of maxillary and mandibular third molars
(9).
Winter classify the impacted wisdom
teeth depending on the angulations of the
third molars(10)
Retention of the impacted teeth may be
associated with Complication that may
include neoplasm, cysts, fracture of
mandible and injury to adjacent teeth
usually through pathological root
resorption or development of periodontitis
etc .(11)
Studies have shown that patients with
retained impacted third molars are
significantly more susceptible to
mandibular angle fracture (1, 12)
While there is a consensus about the
advisability of removing impacted third
molars that cause important pathology or
clinical manifestations, The risk of surgery
and associated complications are justified
and uniformly accepted by most surgeons.
The issue of prophylactically
removing of asymptomatic molars has
been the subject of debate for years. (13,
14,15 )
An indication for extraction of
impacted lower wisdom teeth , reported in
studies include
pericoronitis; which is un inflammation
of the gingival tissue surrounding the
crown of
a tooth, (16,17).
Caries and its sequelae involving the
lower 7 or 8 is indication for wisdom tooth
extraction that been mentioned in many
literatures. (13,18,19,20,21,22)
Periodontal tissue damage on adjacent
tooth was considered as a definite
indication for extraction for.(19,21,23,).
Pathologic entities like cysts, tumours
and root resorption were also reported to
be definite indication for extraction
(18,24)
Orthodontic reason for extraction ;
there is little rationale based for extraction
of impacted molars to minimize present
or future crowding .(25,26,27,28,29)
The specific aims of this study was
asses the prevalence of impaction
,angulation of impacted tooth according to
winter classification and the depth of
impaction according to Pell and Gregory
classification system , complications of the
impacted teeth retention and the indication
for extraction.
Material And Methods
A pilot study that has been undertaken
in the Hospital of Surgical Specialization/
Baghdad Medical City for the duration
2011 -2014.
The total number of patients included
in the study were 880 patients, the sample
consist of 498 (56.59%) male and 382
(43.4) female with age range from 18 to
40.
Age, sex and general health where
recorded
All patients were clinically and
radiographically examined. The OPG was
taken for all patients at hospital of surgical
specialization utilizing OPG device
(PLANMECA OY 00880 HELSINKY
FINLAND).
Inclusion criteria
1- Patients between 18 and 40 years old
were included
2- Patient with no history of extraction of
permanent second and third molar
have been undertaken before the study .
3- No filling for wisdom teeth or the
second molar been undertaken before
the study .
4- Patients have been viewed clinically
and OPG has been taken for them .
5- Patients were physically fit with no
systemic disease.
62-05 )2016( 4….Impacted wisdom teeth
52
Exclusion criteria:
1- Aged younger than 18 years and above
40 years
2- A history of dental extraction of
permanent second and/or 3rth molar
3- Previous orthodontic treatment.
4- Any history of abnormal endocrine
disturbance.
5- Any craniofacial anomaly or syndrome
such as Down syndrome; cleidocranial
dysostosis;
6- The presence of incomplete records of
patient medical history or physical
finding
7- Poor quality OPG.
Third molar was considered impacted if it
was not in functional occlusion and at the
same time, its roots were fully formed.
The angulation was assessed by
measuring the angle formed between the
long axis of the third molar relative to the
long axis of the second molar, using an
orthodontic protractor (Table 1).
At the same time depth of impaction was
assessed according to winter classification
in which Level A_ The impacted tooth
occlusal plane, is at the same level as the
second molar occlusal plane.
Level B_ The impacted tooth occlusal
plane located between the occlusal plane
and the cervical line of the second molar.
Level C_ The impacted tooth occlusal
plane located below the cervical line of the
second molar. (Pell and Gregory)
In the current study we analyze the
complications and indications for
extraction of impacted wisdom teeth and
classified the indications for extraction in
to (orthodontic reasons, caries,
pericoronitis, damage to the adjacent teeth
roots or bone, pain and patient request
The Federation Dentaire Internationale
Numbering System (FDI) was used. In
which (the maxillary right quadrant is
assigned the number 1, the maxillary left
quadrant is assigned the number 2, the
mandibular left quadrant is assigned the
number 3, and the mandibular right
quadrant is assigned the number 4).
Result:
The total number of 880 patients were
included in the study, the sample consist
of 498 (56.59%) male and 382 (43.4%)
female (table 2) with age range from 18 to
40 and mean of 28.8.
Of 880 patients 411pstients showed
impaction of at least one tooth (table 3)
.The total number of impacted teeth in the
sample was 1100 and 57 missing teeth
(table 4). The study demonstrate that there
is highest percent for 4 teeth impaction
and lowest for 3 teeth impaction (table 5)
The study showed that Radiographic
level of impaction according to Pell and
Gregory was highest in level C impaction
in both mandibular and maxillary wisdom
teeth and lowest in level A for maxillary
impacted wisdom tooth (table 6)
Total number of mandibular impacted
wisdom teeth were 672 while maxillary
impacted wisdom tooth were 428 (table 7
and 8).
The highest pattern for impacted teeth
was vertical impaction and lowest was
inverted for both maxillary and
mandibular teeth (table 7 &8) .the highest
pattern for impacted upper wisdom teeth.
Orthodontic reason was the main cause
for extraction followed by pericoronitis
and both of them were significant P<0.05
Significant (table 9) and lowest was
associated lesions (table 9). Fracture, root
resorption and associated lesions were
insignificant p>0.05 437 impacted teeth
of 1100(39.7%) ,the surgeon decide to
leave it without extraction, embark on wait
and see policy as the impacted teeth were
asymptomatic clinically and sound clean
radiographically.
Discussion
Extraction of third molars remains one
of the most common procedures practiced
by oral surgeon and indications for referral
to Oral and Maxillofacial surgeons. Third
molar have been described as different
from other teeth in the oral cavity. They
have the highest rate of development
abnormalities and are the last in the
eruption sequences. (13).
1. The prevalence of impaction
The most widely accepted concepts
which cause impaction include angulation
62-05 )2016( 4….Impacted wisdom teeth
53
of the tooth, available space for eruption
(typically regarded as the space from the
anterior aspect of the ascending ramus to
the distal of the second molar)The space
for third molar is found to be diminished
when the growth rate in length of the
mandible is slight .
The reported prevalence in this study
higher than that reported by Eliasson et al ,
Hattab et al ,Monteluis, (30.3%, 33% ,32
)respectively (30,31,32), and Rajasuo et al
(38 %)(33), Ali.H. Hassan (40.5 %) in
Saudi population(34)
On the other hand ,the prevalence of
impaction is less than that reported by
Leukman fawzi omar(50.17 %) in hawler
young people (35) Morris and Jerman
(65.5 %) in USA respectively (36) . And
Quek et al, who reported (68.6%) in
Singapore.(37)
In india study shows (41.2% )had
impacted third molar (38). which is
equivalent to studies done by Kramer and
Williams in afro- Americans (8) .And
Dachi and hoewel in Columbia.(39)
2. Angulations of impaction
The mandibular third molar begins its
development in the ramus with its occlusal
surface facing mesially; to achieve normal
position it must upright to a degree to its
original angulations. Failure of this
movement Explain the mesial pattern of
impaction, and insufficient retromolar
space lead to vertical angulations
impaction. (40).
The current study shows that vertical
pattern of impaction was the highest
approaching (59.8 %) table no (7&8) in
contrast to other studies which stated that
mesial angulation was the highest
incidence .Although all the results share
the same low incidence of distal
angulation .
(41, 42). Ali.H. Hassan,in his study
showed that the mesio-angular make the
highest percentages (33.4 %) in Saudi
population (34).
The most probable explanation for this
variation in the result was attributed to
different criteria for definition of
impaction and the second reason was the
previous study used OPG as a sole criteria
for classification of teeth as being
impacted or erupted in these situations the
teeth in level A and some of level B which
is partieally erupted and usually vertically
oriented will be considered as erupted and
will be omitted from the lists.
3. level of impaction
Our results show clearly in (table 6)
that level C impaction was the most
common for both maxilla and mandible
(61 .5 %), While Yahya et al study
showed that level A was the highest one
(65.%). (41) While Tahrir agree with our
result although he give less percentage for
level C (33%) of the cases.(42).Ali.H.
Hassan , the level B( 48.2 %) the most
common level in Saudi population(34) .
The protocol for third molar removal
include determining the angle and level of
impaction by the aid of plain x-ray so as to
assess the difficulty and the probable
complications during extraction.
Accordingly impactions within level B
indicating that the extractions would be
moderately difficult. Impaction in level C
may need extraction under general
anesthesia depend on the surgeon’s
evaluation and the patient’s preference,
(43).This may explain the higher
percentage of level C impaction which
was shown in this study because less
difficult procedures can be done in private
clinics and under local anesthesia mostly.
While our research have been executed in
hospital of surgical specialization which
receive referral for difficult cases .
4. Number of impacted teeth
In our sample the study demonstrate
that the prevalence of 4 impacted molars
in for single person was the highest (36.98
%). Followed by presence of 2 impacted
teeth for same individual (29.92%),The
least one is with 3 impacted teeth
(13.38%),while (19.70%) of cases with
single impacted tooth (table 5).
Ali.H. Hassan, found the most
prevalent impacted third molar per OPG
was one (72.5%) and least common
number was four (3.3 %) (34)
The most probable explanation for this
variation in the result was attributed to
different criteria for definition of
impaction and the second reason was the
previous study used OPG as a sole criteria
to classify the teeth as being impacted or
erupted in these situations the teeth in
level A and some of level B which is
partially erupted be considered as erupted
62-05 )2016( 4….Impacted wisdom teeth
54
and will be omitted from the lists. In our
criteria the tooth must be reaching the
occlusion and stand functionally.
5. Agenesis
In our study the percentages of missing
third molars was (1.61%) (table 4 ) is far
away from result given by ,Ghada A.
Yaseen ,in her study shows the prevalence
of agenesis was ( 24 % ) .(44) and be little
bit narrower than (6.4 %) missing in
Leukman fawziomar study at hawler
young people.(35) .Impacted third molar
Agensis in Indian study was (12.2-12.5 %
).[38)
This variation can be attributed to
deficiency of the date obtaining from the
patient and consider the absence teeth as
congenital missing teeth.
6. Indication for extraction
The National Institute for Clinical
Excellence introduced these guidelines in
March 2000 to provide guidance for
dentists and surgeons on deciding when
wisdom teeth should be removed which
are Unrestorable caries, Fracture of tooth,
Non-treatable pulpal and/ or periapical
pathology , Pathology of follicle including
cyst/tumour ,Cellulitis or abscess
formation ,Osteomyelitis ,Tooth /teeth
impeding surgery e.g. Reconstructive jaw
surgery, pre-prosthetic/implant surgery,
orthognathic surgery, tooth involved
within the field of tumour resection and
Internal/external resorption of the tooth or
adjacent teeth.
The prophylactic removal of third
molars was not recommended by NICE
(45, 46).
Routine removal of the impacted
wisdom teeth should be avoided as the
operations have some draw back that may
include Pain , hemorrhage trismus dry
socket , periodontal damage TMJ
problem sinus exposure and paresthesia or
anesthesia, iatrogenic damage to adjacent
structures , fractures of adjacent tooth , in
addition the surgical removal is coasty
procedures all these reasons make
prophylactic removal of sound a
symptomatic impacted molar as hazardous
procedures (47,48)
In the context of orthodontic indication
, extraction was in done in about 18.25%
of the extracted cases (table 10 ) that equal
to 11 % (table 9) of patients with impacted
teeth in the current study . Studies
demonstrate variable result ranging from
14% up to 35% for orthodontic reasons.
(18, 49)
Many studies found a greater
percentage of dental crowding in subjects
with erupting third molars in comparison
to subjects with congenitally missing third
molars, (50). For this reason many
orthodontist used to send their patients for
extraction of third molars in our surgical
department.
At present time there is little rationale
based as evidence for extraction of lower
third molars solely to minimize the present
or future crowding of lower anterior teeth
(25, 26, 27, 28, 29).
The pericoronitis 14.7 % was the
second cause for extraction in our surgical
department according to our study,
Nordenram et al mentioned in his study
that the pericorontis is the main
pathological indication in about (60 % )of
the cases.(51)While Adeymo et al in his
study found that carries and its sequel was
the main cause for surgical removal
followed by recurrent pericoronitis .
(13).The proportions in other studies have
varied between 8-59% (18).
Caries as an indication for extraction in
our study was 12.97% with reported
incidence in varies from 13 % up to 63.2%
(18, 19).
Bone resorption and periodontal
damage to the adjacent teeth was
responsible for 10.4% of the indication for
extraction( table10) , that coincide with
reported in the literatures which been
estimated ( 1% - 8.9%).(19,21,23)
Root resorption of second molars by
the impacted 2nd molar in our study was
3.9% (table10) and this is coincide with
Mercier and Precious (1992) in their
review quoted the prevalence ranging
between 00/0 - 3.10/0. (21)
Pathologic entities like cysts, tumours
in our study was 2.56 of the extracted
wisdom teeth that equal to 1.45% of the
whole impacted teeth sample (table 9) and
these finding coincide with the finding by
Lysell L et al and Guven O et al whom
reported less than 3% (18,24). In our
sample even the impacted teeth with
enlarge follicular cyst have been removed
together and send for biopsy and this
62-05 )2016( 4….Impacted wisdom teeth
55
coincide with recommendation of national
institute of dental research. (23)
Prophylactic removal of the wisdom
teeth was 8.26 of the impacted sample
(1100 teeth) (table 9) that equal to 13.72
of the extracted sample (table 10)
The prophylactic removal of the teeth
was reported as low as low as 7.7%.up to
the extreme of 51% (18,49,52).These
variation attributed to method of
measuring the sample weather the
percentage from the whole impacted
sample or from the extracted wisdom teeth
in addition the prophylaxis may include
many items (before irradiations , when the
patent develop lesions in one quadrant we
remove other wisdom teeth as precaution ,
when patient admitted to remove single
tooth for any other reasons under GA we
remove all other wisdom teeth
Under the cover of Others as an
indications for removal of impacted teeth
include (orthognathic surgery,
preprosthetic surgery and implant) have
been reported to be 3.31 in our study
Vague Pain as indication for removal
of 3rd molar was 11.3 of the extraction
sample
Mandibular fracture on other hand as
an indication for removal was
2.41.Mandibular fracture occur due to
abrupt change in the angulations of
mandible at the angle of mandible and the
presence of tooth structure which
quantitatively affect the existing bone
increased risk of mandibular fractures
which is one of the most common fracture
site especially the incompletely erupted 3rd
molar (53).Teeth in the fracture line can
interfere with and or fixation of fractures
segment therefore its removal is
encouraged in most situations
Pain and patient request and other none
significant indication can be seen under
the cover of prophylactic or others, in
various literatures therefore could not find
research to compare with in isolation.
Conclusion
A- Concerning impaction pattern, the
mandibular wisdom teeth impaction is
more prevalent than maxillary wisdom
teeth with vertical impaction is
commonest followed by mesioangular
impaction while the inverted impaction is
negligible .Level C impaction is the most
common in both maxilla and mandible
B- Agenesis of third molar may occur but
of low significant 1.61 %
C- Indications for extractions
1. Although orthodontic reason was the
commonest reason for extraction , but
up to this moment , there is no clear
and consensus evidence for extraction ,
the debate will continue until clear cut
evidence appear .
2. Periocoronits and caries appear to be
the most practical and logical reason
for extraction especially after failure of
other treatment modalities .
3. Root resorption or bone and
periodontal damage of the adjacent
tooth took place as a good reason for
extraction of impacted wisdom teeth .
4. Pathological reason is absolute
indication for removal of impacted
teeth , even though its occurrence rate
was low 1.54 %
5. Prophylactic removal of the impacted
teeth should be prohibited as surgical
treatment is not without complication
.Even prophylacticlly to avoid
mandibular fracture is not without
complication and better to be avoided .
6. If prophylactic treatment involving
tumor , biopsy , to prevent post
irradiation osteoradionicrosis , or the
patient is medically compromised or as
a part of preparation to orthognathic
surgery or prosthetic surgery in these
situation it is indicated
7. The study demonstrate higher level of
wait & see policy and this is obvious
from number of impacted teeth that
have been left insitue which proved to
be effective and good measure as
proved also by many literatures .
(25,26,27,28,29,45,46, 51.52)
8. The oral surgeon should build his
decision to extract or not extract third
molars on the most canonical scientific
guidelines and what is best for each
individual case.
62-05 )2016( 4….Impacted wisdom teeth
56
Table1: Angulations of impaction
Table 2: Female to male number and percentages.
Patients
No.
%
Female
382
43.41%
Male
498
56.59%
Total
880
100%
Table 3: Number and percentages of the patients with & without impaction.
Table 4: Teeth status.
Supposed Total teeth number
3520
100%
Erupted teeth
2363
67.13
Impacted teeth
1100
31.25
Missing teeth
57
1.61
Table 5 : Impacted teeth’s number for each patients ; IN= patient with single tooth
impaction , N2= patient with 2 impacted teeth , IN3= patient with 3 impacted teeth ,
IN4= patient with 4 impacted teeth.
Impaction
Angulations
Vertical impaction
10° to -10°
Horizontal impaction
80° to 100°
Mesioangular impactions
Distoangular impaction
Inverted impaction
Bucolingual
Bucolingual orientation or
bucopalatal orientation
11° to 79°
-11° to -79°
111 to -111
Any impaction that oriented
bucolingual with crown overlapping
the roots
Any tooth orientation in
bucolinigual or bucopalatal directon
with crown overlapping the roots
Distoangular impaction
-11 to -79
Inverted impaction
101 to 180/ -101 to -180
Buccolingual impaction
That orientation in buccolingual
direction with crown overlap roots
Total Patients
number
880
100%
Patients with
Erupted teeth
469
53.29
Patients with
Impacted teeth
411
46.7
Impaction number
No.
% of total
patient=880
% of total
impaction =411
IN.1
81
9.2
19.70%
IN.2
123
14
29.92%
IN.3
55
6.25
13.38%
IN.4
152
17.3
36.98%
62-05 )2016( 4….Impacted wisdom teeth
57
Table 6: Iimpaction level according to Pell and Gregory, LEV= level, MX= maxillary,
MD=mandibular.
Radiograph impaction level
No.
%
LEV A MX
4
0.36
LEV A MD
208
18.9
LEV B MX
56
5.09
LEV B MD
156
14.2
LEV C MX
363
33
LEV C MD
313
28.5
Total
1100
100
Table 7: Aangulations of impacted lower wisdom teeth, MD =mandibular, MI
=mesioangualr impaction, VI=vertical impaction, DI=distoangualr impaction,
HI=horizontal impaction. IN= inverted impaction, Buco =bucolingual impaction.
Angulations
Patients No.
% related to mandibular
wisdom
% related to total
impaction number
(1100)
M.I.MD
184
27.38
16.7
V.I.MD
407
60.56
37
D.I.MD
14
2.08
1.27
H.I.MD
51
8.18
4.64
IN.I.MD
3
.44
0.27
buco Man
13
1.93
1.18
Total mandibular
impaction
672
% related to mandibular
wisdom
61%
Table 8: Angulations of upper impacted wisdom teeth MX=maxillary.
Angulations
Patients No.
% related to max
wisdom
% related to total impaction
number(1100)
M.IMX
19
4.4
1.73
V.I.MX
251
58.6
22.8
D.I.MX
150
35.04
13.6
H.I.MX
5
1.16
0.45
IN.I.MX
1
0.23
0.09
bucoMx
2
0.46
0.18
Total maxillary
impaction
428
% related to total impaction
number(1100)
62-05 )2016( 4….Impacted wisdom teeth
58
Table 9: Demonstrating the appropriate management modality for impacted
wisdom teeth extraction in the current study *P<0.05 Significant . **P>0.05
Non-significant.
Indication
Extraction
Leave it
No.
%
P-value
Orthodontic
Extraction
121
11.2
0.026
pericoronitis
Extraction
98
8.89
0.023
Prophylactic
Extraction
91
8.26
0.027
Caries
Extraction
86
7.8
0.018
Pain
Extraction
75
6.81
0.013
bone resorption
Extraction
69
6.26
0.006
Root resorption
Extraction
43
3.9
0.096
Patient request
Extraction
25
2.27
0.072
Other
Extraction
22
2
0.092
Associated lesions
Extraction
17
1.54
0.145
#line
Extraction
16
1.45
0.135
Asymptomatic teeth that appeaar sound
clinically & radiographically
Leave it
437
39.7
0.002
Totals
1100
100
-
Table 10: indications for extraction.
Indication
No.
%
Orthodontic
121
18.25
pericoronitis
98
14.7
Prophylactic
91
13.72
Caries
86
12.97
Pain
75
11.3
bone resorption
69
10.4
Root resorption
43
6.4
Patient request
25
3.7
Other
22
3.31
Associated lesions
17
2.56
#line
16
2.41
Totals
663
100%
62-05 )2016( 4….Impacted wisdom teeth
59
Figure 1: A-Horizontal impaction, B-Buccolingual impaction, C-Inverted mandibular
impaction and vertical impaction of maxillary 3rd molar.
Figure 2: A-Odontoma, B- Cystic lesion.
62-05 )2016( 4….Impacted wisdom teeth
60
Figue 3: Fracture mandible and mesioangular impaction.
References
1. DimitroulisG .A Synopsis of Minor
Oral Surgery. Oxford university
press: 1997. Chapter 6, pp 48-57.
2. Obimakinde OS. Impacted
mandibular third molar surgery; an
overview Dentiscope, 2009; volume
16, January
3. Brickley M, Armstrong R, Shepherd
J, Kay E. (I) The relevance of health
state utilities to lower third molar
surgery. International Dental Journal
1995; 45: 124-128.
4. Scottish Intercollegiate Guidelines
Network (SIGN). Management of
unerupted and impacted third molar
teeth.A national clinical guideline,
SIGN 43, 2000.
5. Schersten E, Lysell L, Rohlin M.
Prevalence of third molars in dental
students. SWED DENT J 1989;13:7-
13.
6. Ylipaavalniemi P, Turtola L,
Murtomaa H, Rytomaa I. Evaluation
of the need for third molar removals
among 20- to 21- years old Finnish
university students. PROC FINN
DENT SOC 1985;81:222-5.
7. Hman M. Our third molar teeth: their
eruption, presence and absence.
Dental Cosmos 1936; 78:750-62.
8. Kramer RM, Williams, AC. The
incidence of impacted teeth. ORAL
SURG ORAL MED ORAL PATHOL
1970 ; 29:237-41.
9. Pell GJ, Gregory BT. Impacted
mandibular third molars:
classification and modified
techniques for removal. Dent Digest.
1933;39:330–338
10. Winter GB. The Principles of
Exodontia as Applied to the Impacted
Third Molar.St. Louis, MO:
American Medical Book Co; 1926
11. Ma’aita J and Alwrikat A . Is the
mandibular third molar a risk factor
for mandibular angle fracture? Oral
Surg Oral Med Oral Pathol Oral
RadiolEndod, 2000;89(2): 143-146
12. Fuselier JC, Ellis EE 3rd and Dodson
TB .Do mandibular third molars alter
the risk of angle fracture? J Oral
Maxillofac Surg, 2002; 60(5): 514-
518.
13. Adeyemo WL. Do pathologies
associated with impacted lower third
molars justify prophylactic removal?
A critical review of the literature.
Oral Surg Oral Med Oral Pathol Oral
RadiolEndod. 2006 Oct;102(4):448-
52.
14. Mettes TG, Nienhuijs ME, Van der
Sanden WJ, Verdonschot EH,
Plasschaert AJ. Interventions for
treating asymptomatic impacted
wisdom teeth in adolescents and
adults.Cochrane Database Syst
Rev.2005 Apr 18;(2):CD003879.
15. Bagheri SC1, Khan HA. Extraction
versus non extraction management of
third molars. Oral Maxillofac Surg
Clin North Am.2007 Feb;19(1):15-
21, v.
62-05 )2016( 4….Impacted wisdom teeth
61
16. Bruce, RA, Frederickson GC, Small
GS. Age of patients and morbidity
associated with mandibular third
molar surgery. JADA. 1980;101:240-
5.)
17. Worrall S, Riden K, Haskell R,
Corrigan A. UK National Third
Molar project: the initial report.
Journal of Oral and Maxillofacial
Surgery 1998; 36: 14-18.))
18. Lysell L, Rohlin M.A study of
indications used for removal of the
mandibular third molar, Int J Oral
Maxillofac Surg. 1988 Jun;17(3):161-
4.
19. Polat HB1, Ozan F, Kara I, Ozdemir
H, Ay S. Prevalence of commonly
found pathosis associated with
mandibular impacted third molars
based on panoramic radiographs in
Turkish population.2008
Jun;105(6):e41-7. doi:
10.1016/j.tripleo.2008.02.013. Epub
2008 Apr 16.
20. Macgregor AJ. The impacted lower
wisdom tooth. Oxford: Oxford
University Press,1985.
21. Mercier P and Precious D. Risks and
benefits of removal of impacted third
molars. J Oral MaxillofacSurg 1992;
21:17-27.
22. Toth B. The appropriateness of
prophylactic extraction of impacted
third molars. A review of the
literature. Health Care Evaluation
Unit, University of Bristol, 1993.
23. National Institute of Health. NIH
consensus development conference
for removal of third molars. J Oral
Surgery 1980; 38:235-236
24. Guven 0, Keskin U, Akal U. The
incidence of cysts and tumours
around impacted third molars.
International Journal of Oral and
Maxillofacial Surgery 2000; 29[131]:
135.
25. Bramante MA. Controversies in
orthodontics. Dental Clinics of North
America 1990; 34(1):91-102.
26. Southard TE. Third molars and
incisor crowding: when removal is
unwarranted. JADA 1992; 123:75-79.
27. Vasir NS, Robinson RJ. The
mandibular third molar and late
crowding of the mandibular incisors -
a review. Br J Orthodon 1991; 18:59-
66.
28. Song F, Landes D, Glenny A,
Sheldon T. Prophylactic removal of
impacted third molars: an assessment
of published reviews. British Dental
Journal 1997; 182:339-346.
29. Harradine N, Pearson M, Toth B. The
effect of extraction of third molars on
late lower incisor crowding: A
randomized controlled trial. British
Journal of Orthodontics 1998;25:117-
122.
30. Eliasson,S,HeimdahlA.Pathological
changes related to long- term
impaction of third molars . A
radiographic study. Int J Oral
MaxillofacSurg1989 ;18940:122-125.
31. Hattabfn, Fahmyms ,Rawashedhma
.impaction status of third molars in
Jordanian students. Oral Surg oral
med pathol radio endod.
1995;79(1):24-29.
32. Monteliusga .Impacted teeth . ; a
comparative study of Chinese and
Caucasian dentitions. J dent res .1932
; 1`2 960; 931- 938.
33. Rajasuoa ,Murtomaa h , merurmanjh .
comparison of the clinical status of
third molars of young men in 1949
and in 1990. Oral surg oral med oral
pathol.1993;76(6);649-698.
34. Ali.h. Hassan.; Pattern of third molar
impaction in a Saudi population
clinical, cosmetic and investigational
dentistry.2010;2; 109-113.
35. Lukman .Fawaziomer. ;prevalence of
impacted wisdom teeth among
Hawler young teeth among hawler
young people;MDJ.vol5.no
1;2008;97-100.]
36. Morriscr ,Jermanac . panoramic
radiographic survey ;a study of
embedded third molars .j oral surg
.1971; 29 (2) 122-125.],
37. Quek SL , Tay CK , Tay KH , Toh Sl
, Lim KC . pattern of third molar
uimpaction in a Singapore Chinese
population; a retrospective
radiuographic survey . int j oral
maxillofac surg 2003 Oct; 32 (5)
;584- 52.
38. Ananthalakshmi Ramamurthy ,jey
Prada , SathiyaJeeva , NadeemJeddy ,
J Sunitha, Selva Kumar.; Prevalence
62-05 )2016( 4….Impacted wisdom teeth
62
of Mandibular Third Molar Impaction
and agenesis ; A Radiographic south
Indian study , Journal of Indian
Academy of Oral Medicine and
Radiology , July –September 2012
;24 (3 );173-176 10.5005/journals-
10011-1289
39. Dachiu SF, Howell FV . a survey of
3874routine full-mouth radiographs ;
II . a study of impacted teeth .J Oral
maxillofac Surg 1961 ; 14 ;1165-41.
40. Ragini,NavjotS.Prajeesh P .
Prediction of third molar eruption.
JIndOrtho Soc2003:36:103-112
41. YahyaA.Ali and AqeeL Ibrahim
,Impacted lower third molars as a
clinical study of 140 cases; journal of
Humanities college number (second
)/year (2012);1-10.
42. Tahrir Nasal Al-Delaimi ,Suheir
Wadea Abood, Afrah Adnan Khalil
.the evaluation of impacted third
molars using panoramic radiograph;
MDJ; Vol 8;No;1 , August 2010 ,
ISSN; 2070-8882; 26- 33
43. A Björk, E Jensen, M Palling
,Mandibular growth and third molar
impaction
-ActaOdontologica Scandinavica, 1956 -
Taylor & Francis
44. Ghada A. Yaseen, Third molar
agenesis , J Bagh College Dentistry ,
Vol. 17 (3), 2005;101-104.]
45. Gintaras Juodzbalys Povilas Daugela,
Mandibular Third Molar Impaction:
Review of Literature and a Proposal
of a Classification .. J Oral
Maxillofac Res. 2013 Apr-Jun; 4(2):
e1.
46. Lytle JJ.Etiology and indications for
the management of impacted teeth.
Northwest Dent. 1995 Nov-
Dec;74(6):23-32
47. M. Angeles Fuster Torres, Jordi
Gargallo Albiol, Leonardo
BeriniAytes, Cosme Gay Escoda.
Evaluation of the indication for
surgical extraction of third molars
according to the oral surgeon and the
primary care dentist. Experience in
the Master of Oral Surgery and
Implantology at Barcelona University
Dental School. Med Oral Patol Oral
CirBucal. 2008 Aug 1;13(8):E499-
504.
48. KonstantiniaAlmpaniOlga-
ElpisKolokitha . Role of third molars
in orthodontics World J Clin Cases.
2015 Feb 16; 3(2): 132–140.
49. NordenramA ,Hultin M, Kjellman O,
Ramstrom G.; Indications for removal
of the mandibular third molar . study
of 2,630 cases. Swed Dent J 1987;
1191-2023-9.]
50. Bataineh AB, Albashaireh ZS,
Hazza’a AM. The surgical removal of
mandibular third molars: a study in
decision making. Quintessence Int.
2002 Sep;33(8):613-7.
51. Samir E. Bishare , third molars: A
dilemma ! Or is it? Am J Orthod
Dentofacial Orthop . June1999 volum
115, issue6 ,page 628-633 )
52. Friedman JW. the prophylactic
extraction of third molars : a public
health hazard . Am J Public Health
.2007 Sep; 97(9):1554-9
53. Lida, Seiji ; Nomura , kimiko; Okura
, Masaya ;Kogo , Mikihiko . influence
of the incompletely erupted lower
third molar on mandibular angle and
condylar fractures . journal of trauma
–injury infection &critical care
.September 2004-volume 57 –issue 3
–pp613-617.
