ORIGINALARTICLEPrevalenceofimpactedthirdmolarsandthereasonforextractio - PDF document

ORIGINALARTICLEPrevalenceofimpactedthirdmolarsandthereasonforextractioninSaudiArabia LinaAlfadil,EmtenanAlmajedRiyadhElmUniversity,Riyadh,SaudiArabiaOralMaxillofacialSurgeryConsultant,DepartmentofOralMaxillofacialSurgery,PrinceSultanMilitaryMedicalCity,Riyadh,SaudiArabiaReceived4November2019;revised25December2019;accepted5January2020Availableonline13January2020KEYWORDSThirdmolar;Impacted;Prevalence;Extraction;SaudiArabia;WinterclassiÞcation;PellandGregoryclassiÞca-ThisstudyaimstorecordthecurrentpatternofthirdmolarimpactionsandrelevantreasonsforextractioninRiyadh,SaudiArabia.Wehypothesizedthattheprincipalreasonforextractionwaselective.MaterialandMethods:Orthopantomograms(OPG)radiographsandelectronicÞlesrelatingto4000patientswereretrospectivelycollectedfrompatientsbetweentheagesof21and50yearsold.Ofthese,1014wereincludedinthisstudy(514females,500males).TheclassiÞcationwasdeter-minedaccordingtotheWinter,Pell,andGregoryclassiÞcation.Theanalysiswasdoneusingthechi-square()test,withSPSSversion25(IBM,Inc,Chicago,IL).A-valueof0.05wascon-sideredstatisticallysigniÞcant.Atotalof2240impactedthirdmolarswerefoundwithnogenderpredilection.Impac-tionwasmorecommonlyfoundinthemandible(58.5%)thanthemaxilla(41.5%).Themostcom-monreasonforextractionwasÔasymptomatic;prophylacticindicationÕ(66.8%),followedbyÔsymptomaticÕ(33.2%).Verticalangulationwasmostcommoninthemaxilla(56.5%),andmesioangularimpactioninthemandible(40.5%).ThereisahighrateofthirdmolarimpactioninthecentralregionofSaudiArabia.Itismorelikelytooccurinthemandiblethanthemaxillawithnogenderpredilection.Themajorityofthepatientswerereferredforelectiveasymptomaticreasons.Mesio-angularimpactionismostlyfoundinthemandibleandverticalangulationinthemaxilla.BotharcheshadaCleveldepthandClassIRamusrelationship.FurtherstudiesshouldbeconductedwiththewiderKingdomofSaudiArabiasothatthepopulationcanbemoreaccuratelyrepresented.2020TheAuthors.ProductionandhostingbyElsevierB.V.onbehalfofKingSaudUniversity.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/ Correspondingauthorat:RiyadhElmUniversity,12734KingFahadBranchRd,Riyadh,SaudiArabia.E-mailaddress:Dr.LinaAlfadil@gmail.com(L.Alfadil).ThisresearchdidnotreceiveanyspeciÞcgrantfromfundingagenciesinthepublic,commercial,ornot-forproÞtsectors.PeerreviewunderresponsibilityofKingSaudUniversity. Production and hosting by Elsevier SaudiDentalJournal(2020),262Ð268 KingSaudUniversitySaudiDentalJournalwww.ksu.edu.sawww.sciencedirect.com https://doi.org/10.1016/j.sdentj.2020.01.0022020TheAuthors.ProductionandhostingbyElsevierB.V.onbehalfofKingSaudUniversity.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/ 1.IntroductionThetermimpactedtoothdeÞnesatoothÕsfailuretoeruptwithintheexpectedamountoftimeintothedentalarchunlessintervenedwithtreatment(Mustafa,2015).Failuretoerupt,followedbyimpactionisacommondentalanomalyAkarslanandKocabay,2009;BisharaandAndreasen,1983;Fardietal.,2011;Hashemipouretal.,2013;Lindenetal.,).Interestingly,theincidenceofimpactedteethdiffersacrossdifferentpopulationsandethnicgroups(BisharaandOrtho,1992).Thisfailureoftheeruptioncouldbeduetomanysystemicandlocalfactors,suchascleidocranialdysplasia,DownÕssyndrome,andarch-lengthdeÞciency().Thereisacorrelationbetweenthedevelopmentofperi-coronitis,cysticlesions,andcarieswithimpactedteeth(Anqudietal.,2014).Moreover,thirdmolarshavebeenfoundtobethemostcommonlyimpactedteethintheoralcavityBisharaandAndreasen,1983;Linde

netal.,1995InthePell&GregoryclassiÞcationsystem,thirdmolarimpactionisclassiÞedaccordingtoitsdepthlevelinrelationtotheocclusalsurfaceofthesecondmolarvertically,andtherelationoftheimpactiontothebodyoftheRamushori-zontally(PellandGregory,1933).Asforangulation,thirdmolarimpactionwasclassiÞedbytheWinterÕsclassiÞcationsystemin1926(Winter,1926InSaudiArabia,thelatestassessmentofthirdmolarimpactionswaspublishedmorethan30yearsago(andShalhoub,1986)However,recentlytherehavenotbeenanyarticlesthatdiscussthismatter,andnonewhichtargetthecentralareaofSaudiArabia.ThisstudyaimstorecordthecurrentoccurrencepatternofthirdmolarimpactionsandtherelevantextractionreasonsinasamplelivinginRiyadh,SaudiArabiaWehypothesizethattheprincipalreasonforextractioniselective.Theresultsofthisstudycanhelptoachievemorerel-evantinformation,ofmanyfactors,suchasgender,age,sys-temicdisease,numberofareasandangulation,andpathologicaloccurrence.2.MaterialsandmethodsInthisstudy,retrospectivedatawerecollectedon4000patientsbetweentheagesof21and50yearsoldwhovisitedtheRiyadhElmUniversitydentalclinicsbetweentheyearsof2015Ð2017andhadanelectronicrecord.Ofthe4000patientsscreened,1014wereincludedinthestudyastheyhadatleast1impactedthirdmolar.(514females,500males).ThedatawerecollectedfromallbranchesofRiyadhElmUniversitywhicharelocatedinthreedifferentdistrictsinRiyadhcity.Theestimatederuptiontimeofthirdmolarsrangesbetweentheagesof17and21yearsold.Sinceourstudytargetsimpactedthirdmolars,patientslessthan21yearsoldwereexcludedfromthisstudy.Otherexclusioncriteriaincludedsyndromes(suchasDownÕssyndrome),iftheyhadreceivedorthodontictreatment,hadcraniofacialanomalies,incompleterootformationofthethirdmolars,orwerehigherthanASAIIIundertheSocietyofAnesthesiologists(ASA)classiÞcation.DatawascollectedbyexaminingthepatientsÕOrthopantomo-grams(OPG)radiographsandaccessingtheirelectronicÞleswhichincludedthedetailsofeachprocedureandelectronicreferralforms,whichincludesthereferralreasons.AstheseOPGradiographsweretakenwithroutinedocumentationdur-ingtreatment,noconsentformwasrequired.ApprovalwasgiventoconductthisstudyfromtheRiyadhElmUniversityInstitutionalReviewBoard.PatientswerealsointerviewedoverthephoneforfurtherconÞrmationregardingtheirrefer-ral/extractionreasonanddiagnosis.ThereasonforextractionwasclassiÞedaseithersymp-tomaticorasymptomatic.Symptomaticthirdmolarswerecon-sideredtobethosethattriggeredpainorimpairedmasticationand/orwereassociatedwithacystortumorlesions.TheanglewasassessedusingtheWinterClassiÞcation,whichmeasurestheangleformedbetweenthelongaxisofthethirdmolarandthesecondmolar,relativelywithanorthodonticprotractor(Fig.1a).TheimpactionwasclassiÞedusingthePell&GregoryClassiÞcationsystemforthedepthofthethirdmolarÕscementoenameljunction(CEJ)levelinthealveolarbonecomparedtothesecondmolar(Fig.1b).andtoclassifytheimpactioninrelationtotheanteriorborderoftheRamus(Fig.1Theanalysiswasdoneusingthechi-square()test,withSPSSversion25(IBM,Inc,Chicago,IL).Aof0.05wasconsideredstatisticallysigniÞcant.3.ResultsOfthe4000samplesreviewed,atotalof1014patientswerefoundtohave3840thirdmolars.Ofthese,1600wereerupted41.6%and2240wereimpacted58.3%.(514femalesand500Thedistributionoftheimpactionbetweenthetwogenderswasalmostequal,with50.7%beingfemalesand49.3%males.Theaverageagewas30.67±8.98years(=0.007).ThemajorityofparticipantswereclassiÞedasASAI(97.8%).Patientsmorecommonlyhad2impactedthirdmolars(35.3%),withtheleastcommonbeing3impactedmolars=0.00)(Table1Also,(Table2)displaysthedistributionoftheimpactionpertoothinregardsto

theupperandlowerjaw.Themajoritywerefoundinthemandible(58.5%),withlessinthemaxilla41.5%(=0.018).TherewasstatisticalsigniÞcancebetweenprevalenceintheright(59.9%)andleftsides(40.1%,=0.000).PatientswerecontactedandaskedastowhethertheyhadextractedtheirimpactedteethandtheirÞleswerecheckedfortheirreferralstatus.Fromthis,73.2%ofpatientswerenotreferredforextraction,while26.8%were.Furthermore,almostallpatientsthatwerereferredforanextractionhaveextractedtheirteeth(91.9%,=0.000).Fig.2demonstratesthegivenextractionreasonsfrompatients.Ofthese,ÔÔasymptomatic;prophylacticindicationwasthemostcommonreasonat66.8%,followedbyÔÔsymp-at33.2%.Onthecontrary,98.8%ofthosewhohadnotundergoneanextractionhadÔÔNotindicatedasthemainreasonforretainingtheimpactedthirdmolar(Fig.3Theangulationofimpactionwasalsoevaluated(Table3Verticalangulationwasmostfrequentlyfoundinthemaxilla(56.5%),whichwasfollowedbydisto-angular(31.9%).Inthemandible,themostcommonangulationwasmesioangular(40.5%),whichwasfollowedbyverticalangulation(32.0%,=0.000). PrevalenceofimpactedthirdmolarsandthereasonforextractioninSaudiArabia263 Thedifferentimpactionlevelsaredisplayedin(Table4accordingtothePell&GregoryclassiÞcation.TheClevelimpactiondepthwasfoundtobemostprevalentinboththemandibleandmaxillawith57.3%(=0.000).TheRamusrelationshipclassiÞcationshowedthat66.7%hadaclassIrelationshipinboththerightandleftsideofthemandible.=0.011).Thetypeofimpactionwasassessed.Thisincludedwhetheritwasfullyoronlypartiallyimpactedandwhetherthetypeofoverlyingtissuewasasofttissueorbonyimpaction(Table5Inbothjawsfullimpactionwasmoreprevalent(78.1%)aswascompletelybony(68.8%,=0.000).WhenevaluatingtheOPGsforthepathologicalinvolve-mentofanimpactedthirdmolar,only25patientsoutof1014werefoundtobeassociatedwithapathologicallesion4.DiscussionInalargesampleofthepopulation,thechancesofÞndingoneormoreimpactedthirdmolarisquitehigh.AccordingtoOth-manRetal.,thirdmolarsarethemostcommonimpactedteethtobefoundinhumansandtheirsurgicalextractionisoneofthemostcommondentoalveolarsurgicalproceduresintheoralmaxillofacialsurgicalÞeld(JaffarandTin-Oo,).MultiplefactorscouldberesponsibleforitsetiologyM.andJ.,2004;Syedetal.,2013)Therefore,understandingitspatterninvariouscommunitiesisveryimportant(Pillaietal.,2014Whenevaluatinganimpactedthirdmolarradiographically,theangulationofthemolarshouldbedeterminedaccordingtotheWinterÕsclassiÞcation(Winter,1926).Aswellasthedepthlevelinthebone,therelationshipofthetoothtotheRamusofthemandible,andthesecondmolar,shouldbeincludedaccordingtothePellandGregoryClassiÞcation(PellandGregory,1933;Ayrancetal.,2017Othermeasuresweretakeninassessingtheimpaction,suchastheassociationofpathologicallesions(cysts,tumor)around Fig.1(a)TheWinterclassiÞcationforimpactedthirdmolarangulation.(b)ThePellandGregoryClassiÞcationofimpactedthirdmolardepthinrelationtothecementoenameljunctionofthesecondmolar.(c)ThePellandGregoryClassiÞcationofimpactedthirdmolarsinrelationtotheanteriorborderoftheRamus. Table1Distributionbythenumberofimpaction.NumberofImpactionN(%)1313(30.9)2358(35.3)3152(15.0)4191(18.8)Total1014(100)Asymp.sig.(2-tailed)=0.000Asymp.Sig.,asymptoticsigniÞcance. L.Alfadil,E.Almajed theimpactedtooth.Thenormalpericoronaldentalfollicleisconsideredtobe2Ð3mmradiographically.Theevidenceofradiolucencyaroundthecrownofanuneruptedtooth5mminsizeishighlysuggestiveofadentigerouscystorodontogenictumor(Mesgarzadehetal.,2008;Winter,1926Previously,theprevalenceofthirdmolarimpactionsanditspatternhavebeenstudiedindifferentpartsoftheworldbydif-feren

tauthorslike,(HaidarandShalhoub,1986)inSaudiAra-bia,(KumarPillaietal.,2014)inIndia,(Arabionetal.,2017inIran,andmanyothercountries(Amanatetal.,2014;AhlqwistandGrondahl,1991;Al-Anqudietal.,2014;Yilmazetal.,2016).ThepatternandprevalencehavealsobeenstudiedindifferentareaslocatedinSaudiArabia(etal.,2015;HaidarandShalhoub,1986;Hassan,2010;Syedetal.,2013Ourstudytargetstheincidenceofimpactedteethinasam-plelivinginthecentralpartofSaudiArabia.Thepercentageofimpactionfoundinoursamplewas58.3%whichishigherthan31.9%thatwasfoundbyHaidarandShalhoub(1986andastudyinIndia(KumarPillaietal.,2014).Thesediffer-encescouldbeduetothesamplesize.Themeanage,whendiagnosed,was30.67±8.98years,althoughithasbeenshowntoslightlydifferfrom23.25±4.17years(Arabionetal.,2017)and28.11±7.25yearsHassan,2010Theimpactionincidencebetweenthetwogenderswasfoundtobealmostequal(50.7%femalesand49.3%males).ThisÞndingagreeswithstudiesdonebyHaidarandShalhoub(1986Hassan(2010),anddisagreedwith(etal.,2003;Syedetal.,2013)whoreportedthatmalesweremorelikelytohaveimpactedteeth.Thisresultcouldbeduetothedifferentgrowthpatternsbetweenthetwogenders.Femalesjawgrowth,forthemostpart,endsbythetimethethirdmolarerupts.Nevertheless,thejawgrowthinmalessus-tainsduringtheeruptionofthethirdmolar,givingadequatespaceforthethirdmolartoerupt(Arabionetal.,2017;BisharaandAndreasen,1983 Table2Distributionofimpactedteethintermsofarchlocationandgender.GenderN(%)MaxillaN(%)MandibleN(%)TotalN(%)Male500(49.3)399(38.6)634(61.4)1207(100)Female514(50.7)530(43.9)677(56.1)1033(100)Total1014(100)929(41.5)1311(58.5)2240(100)Asymp.sig.(2-tailed)=0.011Asymp.Sig.,asymptoticsigniÞcance. Fig.2PatientsÕresponsestothereasonforextraction. Fig.3Thegivenreasonsforretainingthethirdmolars. Table3Distributionofimpactedteethintermofangulation.AngleClassiÞcation(WinterÕs)N(%)LocationVerticalMesio-angularHorizontalDisto-angularBuccolingualInvertedTotalMaxilla525(56.5)75(8.1)9(1.0)296(31.9)20(2.2)4(0.4)929(100)Mandible420(32.0)531(40.5)302(23.0)41(3.1)11(0.8)6(0.5)1311(100)Total945(42.2)606(27.1)311(13.9)337(15.0)31(1.4)10(0.4)2240(100)Asymp.sig.(2-tailed)=0.000Asymp.Sig.,asymptoticsigniÞcance. PrevalenceofimpactedthirdmolarsandthereasonforextractioninSaudiArabia265 Havingatleast1impactedthirdmolarwasthemostcom-monlyfoundinpreviousstudiesconcludedbyArabionetal.Hassan(2010).Thisisindisagreementwithourstudy,whichfoundthathavingatleast2impactedthirdmolars,35.5%wasthemostcommonresult.Thisislikelyduetothemeanagebeinghigherinourstudycomparedtothestudiesmentionedabove.Furthermore,whencomparingthedistributionofimpac-tionbetweenthetwojaws,ourstudyshowedthiswashigherinthelowerjaw(58.5%)thanintheupperjaw(41.5%).ThisÞndingisinagreementwith(etal.,2017;KumarPillaietal.,2014)whonotedthatimpactionis1.33morelikelytohappeninthemandiblethanthemaxilla.However,itwastheoppositeofonestudythatwasconductedbyetal.(1995)whofoundimpactiontobe54%higherintheWefoundstatisticalsigniÞcancebetweenthetwosideshav-ingtherightsidemorecommonwith59.9%(=0.018),whichwasfoundinapreviousstudyasinsigniÞcantKaomongkolgitandTantanapornkul,2017Steed(2014)mentionedthatpractitionersshouldbeextractingimpactedthirdmolarswhentheycauseaconsider-ableamountofpain,infection,caries,affecttheadjacentsec-ondmolarorinterferewithprostheticororthodontictreatments.Also,thereareguidelinesregardingtheindicationsforimpactedthirdmolarextractionssetbytheNationalInsti-tuteforClinicalExcellence(NICE,2000).However,evidencetosupportwhethertoextractorretainasymptomatic,disease-freeimpactedthirdmolarsislacki

ng.Manystudieshavedebatedwhethertheextractionofasymptomaticimpactedthirdmolarsisnecessary(Assael,2005;Steed,2014Previousstudiesgavethemainreasonforextractionaspericoronitis,suchas(Gbotolorunetal.,2007;Nordenrametal.,1987).InNordenrametal.,60%werediagnosedwithpericoronitisand4.5%hadcystsrelatedtotheimpaction.Takingthatintoconsideration,ourstudyfocusedontheextractionreasonandwhetherpatientswerereferredforanelectivereasonoranextractionwasrequired.Ourresultsshowthat73.2%ofoursamplewasnotreferredonas98.8%ofthemwerenotindicatedforanextraction.Nevertheless,patientswhowerereferredforextractionhadÔAsymptomatic;ProphylacticindicationÕasthemostprevalentreason(66.8%),whichwasfollowedbyÔSymptomaticÕ(33.2%).Additionally,anumberofstudiesobservedthatverticalangulationismostcommoninboththemaxillaandthemand-ible(etal.,2017;Setal.,2013).Whileothersreportedthatmesioangularimpactionwasthemostcommonpatternofangulationinbothjaws(Arabionetal.,2017).How-ever,inthispresentstudyverticalangulationwasfoundtobemostcommoninthemaxilla(56.5%)andmesioangularimpac-tionwasmostcommoninmandibularimpaction(40.5%).TheseresultsagreewithapreviousstudydoneinthewesternregionofSaudiArabiabyHassan(2010)andKaomongkolgitandTantanapornkul,2017)inThailand.Arabionetal.(2017)foundthatmesioangularimpactionwasthemostcommoninthemandible,butthatdisto-angularimpactionwasmorecommoninthemaxilla.AccordingtothePellandGregoryclassiÞcation,themostrecurrentdepthlevelinourstudywaslevelCinbothjaws(57.3%).OtherstudiesshowedlevelBtobemoreprevalentHassan(2010KaomongkolgitandTantanapornkul(2017Furthermore,multiplestudiesnotedclassIIRamusclassiÞca-tionwasthemostcommon(El-Khateebetal.,2015;KaomongkolgitandTantanapornkul,2017).However,inourstudy,onlyclassI(66.7%)wasstatisticallysigniÞcant=0.008).ThirdmolarimpactioncanbeclassiÞedinto;(1)partialimpaction,wherethecrownpenetratesthemucosaandispar-tiallyvisible;(2)fullimpaction,wherethetoothisnotvisibleintheoralmucosa.AnimpactedthirdmolarthatisfullyenclosedinthejawÕsboneisconsideredabonyimpaction.Asofttissueimpactionisconsideredwhenthecrownoftheimpactedmolarhaspenetratedthebonebutisenclosedinsofttissue(etal.,2003).ThemajorityofimpactionclassiÞedinourstudy,accordingtothemainoverlyingtissue,wasfoundtobebonyandfullyimpacted78.1%,68.8%,respectively(Buietal., Table4Distributionofimpactionintermofdepth,mandibleramusrelationship.ImpactionDepth(Pell&Gregory)N(%)LocationLevelALevelBLevelCTotalMaxilla19(2.0)333(35.8)577(62.1)929(100)Mandible270(20.6)334(25.5)707(53.9)1311(100)Total289(12.9)667(29.8)1284(57.3)2240(100)Asymp.sig.(2-tailed)=0.000ClassIClassIIClassIIITotalMandible874(66.7)359(27.4)78(5.9)1311(100)Asymp.sig.(2-tailed)=0.011Asymp.Sig.,asymptoticsigniÞcance. Table5Distributionofimpactionintermsoftypeandoverlyingtissue.ImpactionTypeN(%)LocationFullyImpactedPartiallyImpactedTotalMaxilla887(95.5)42(4.5)929(100)Mandible862(65.8)449(34.2)1311(100)Total1749(78.1)491(21.9)2240(100)Asymp.sig.(2-tailed)=0.000LocationBonySoftTissueTotalMaxilla603(64.9)326(35.1)929(100)Mandible939(71.6)372(28.4)1311(100)Total1542(68.8)698(31.2)2240(100)Asymp.sig.(2-tailed)=0.000Asymp.Sig.,asymptoticsigniÞcance. L.Alfadil,E.Almajed ).observedthatthiswasthemostcommonsurgicalOdontogeniccystsandtumors�(3mmwidth)associatedwithimpactionshavebeenobservedinmultiplestudieseventhoughtheyarequiterare(Nunnetal.,2013;Santosh,2015;Steed,2014).2.5%ofpatientsinourstudywerefoundtohavesomepathologicalassociationwiththeirthirdmolar.Ofthepatientswithsuchpathologicalchanges,94.4%ofthemwerere

ferredtoasurgeon,andtheirmolarsextracted.WerecommendfurtherstudiesshouldbeconductedwiththewiderKingdomofSaudiArabiasothatthepopulationcanbemoreaccuratelyrepresented.Additionally,alldentistsshouldreferbacktoevidence-basedguidelinesbeforereferringpatientsforanextraction.5.Conclusion(1)Thereisahighrateofthirdmolarimpactionsinthecen-tralregionofSaudiArabia.Thesearemorelikelytobeinthemandiblethanthemaxillawithnogender(2)Themajorityofpatientswerereferredforelectiveasymptomaticreasons.(3)Mesio-angularimpactionismostlyfoundinthemand-ibleandverticalangulationinthemaxilla.(4)BotharcheshadaCleveldepthandClassIRamusDeclarationofCompetingInterestTheauthorshavenoconßictsofinteresttodeclare.Ahlqwist,M.,Grondahl,H.-G.,1991.Prevalenceofimpactedteethandassociatedpathologyinmiddle-agedandolderSwedishwomen.Commun.Dent.OralEpidemiol.https://doi.org/10.1111/j.1600-0528.1991.tb00124Akarslan,Z.Z.,Kocabay,C.,2009.Assessmentoftheassociatedsymptoms,pathologies,positionsandangulationsofbilateraloccurringmandibularthirdmolars:Isthereanysimilarity?OralSurg.,OralMed.OralPathol.OralRadiol.Endodontol.https://doi.org/10.1016/j.tripleo.2009.05.036.Al-Anqudi,S.M.,Al-Sudairy,S.,Al-Hosni,A.,Al-Maniri,A.,2014.Prevalenceandpatternofthirdmolarimpaction:aretrospectivestudyofradiographsinOman.SultanQaboosUniv.Med.J. Amanat,N.,Mirza,D.,Rizvi,K.F.,2014.Patternofthirdmolarimpaction:frequencyandtypesamongpatientsattendingurbanteachinghospitalofKarachi.PakistanOralDentalJ.34(1) Arabion,H.,Gholami,M.,Dehghan,H.,Khalife,H.,2017.Preva-lenceofimpactedteethamongyoungadults:aretrospectiveradiographicstudy.J.DentalMater.Tech.6(3),131Ð137.doi.org/10.22038/jdmt.2017.8940Assael,L.A.,2005.Indicationsforelectivetherapeuticthirdmolarremoval:Theevidenceisin.J.OralMaxillofac.Surg.https://doi.org/10.1016/j.joms.2005.10.001. ,F.,Omezli,M.M.,Sivrikaya,E.C.,Rastgeldi,Z.,2017.Prevalenceofthirdmolarimpactedteeth:across-sectionalstudyevaluatingradiographsofadolescents.J.Clin.Exp.Invest./KlinikveDeneyselArastirmalarDergisi8(2) Bishara,S.E.,Andreasen,G.,1983.Thirdmolars:areview.Am.J.Orthod.https://doi.org/10.1016/S0002-9416(83)90298-1Bishara,S.E.,Ortho,D.,1992.Impactedmaxillarycanines:areview.Am.J.Orthod.Dentofac.Orthop.https://doi.org/10.1016/0889-5406(92)70008-XBui,C.H.,Seldin,E.B.,Dodson,T.B.,2003.Types,frequencies,andriskfactorsforcomplicationsafterthirdmolarextraction.J.OralMaxillofac.Surg.https://doi.org/10.1016/j.joms.2003.04.001 El-Khateeb,S.M.,Arnout,E.A.,Hifnawy,T.,2015.Radiographicassessmentofimpactedteethandassociatedpathosisprevalence:patternofoccurrenceatdifferentagesinSaudiMaleinWesternSaudiArabia.SaudiMed.J. Fardi,A.,Kondylidou-Sidira,A.,Bachour,Z.,Parisis,N.,Tsirlis,A.,2011.Incidenceofimpactedandsupernumeraryteeth-aradio-graphicstudyinaNorthGreekpopulation.Med.OralPatol.OralCir.Bucal.https://doi.org/10.4317/medoral.16.e56Gbotolorun,O.M.,Olojede,A.C.,Arotiba,G.T.,Ladeinde,A.L.,Akinwande,J.A.,Bamgbose,B.O.,2007.Impactedmandibularthirdmolars:presentationandpostoperativecomplicationsattheLagosUniversityTeachingHospital.NigQ.J.Hosp.Med.doi.org/10.4314/nqjhm.v17i1.12537Haidar,Z.,Shalhoub,S.Y.,1986.TheincidenceofimpactedwisdomteethinaSaudicommunity.Int.J.OralMaxillofac.Surg.https://doi.org/10.1016/S0300-9785(86)80060-6.Hashemipour,M.A.,Tahmasbi-Arashlow,M.,Fahimi-Hanzaei,F.,2013.Incidenceofimpactedmandibularandmaxillarythirdmolars:aradiographicstudyinasoutheastiranpopulation.Med.OralPatol.OralCir.Bucal.https://doi.org/10.4317/medoral.18028Hassan,A.H.,2010.Patternofthirdmolarimpactioni

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