|DENTAL SCIENCE - REVIEW ARTICLE
|Year : 2015 | Volume
| Issue : 5 | Page : 251-254
The incidence of cysts and tumors associated with impacted third molars
AT Vigneswaran, S Shilpa
Department of Oral and Maxillofacial Surgery, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||31-Oct-2014|
|Date of Decision||31-Oct-2014|
|Date of Acceptance||09-Nov-2014|
|Date of Web Publication||30-Apr-2015|
Dr. A T Vigneswaran
Department of Oral and Maxillofacial Surgery, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Incidence of cysts and tumors associated with lower impacted third molars are very low prevalence, which might be because of the fact that most pathologies go unnoticed as many practitioners discard the erupted tissue after surgical removal of the impacted teeth rather than sending the tissue for histopathological examination. Our aim was to evaluate the patients who came for third molar surgical removal with due therapeutic prophylacis and an incidental finding. A proper study protocol both inclusion and exclusion criteria was strictly followed for all the cases, which were included in the study. The period of study was 6 years and the total number of cases assessed were 2778 patients out of which 70 cases reported pathology associated with the impacted third molars. Among 70 cases 61.4% were reported as cyst and tumors and 38.6% of the cases had chronic inflammatory reaction, including two cases with normal dental follicle. High incidence rate of pathology associated with third molar occurred between age group of 20 and 30 years older age groups showed very low incidence. Most common site of impaction was found to be left side of mandible and positions were vertical and distoangular impactions. Thus was male predominance in the younger groups. The examination is necessary whether the third molars impacted cases were symptomatic or asymptomatic
Keywords: Cyst, tumor, 3 rd molars, impactions
|How to cite this article:|
Vigneswaran A T, Shilpa S. The incidence of cysts and tumors associated with impacted third molars. J Pharm Bioall Sci 2015;7, Suppl S1:251-4
Impaction is the cessation of eruption or failure of a tooth eruption caused by a physical barrier in the eruption path, abnormal positioning of the tooth and the loss of space or other impediments. Various authors have conducted studies to assess the prevalence of erupted and impacted third molar of patients ranging from the young to the elderly within a range of 6-14%. However, studies show low incidence of cysts and tumors associated with impacted third molars which might be because of the fact that most pathologies go unnoticed as many practitioners discard the erupted tissues after surgical removal of the impacted teeth rather than sending the tissues for histopathological examination.  The literature agrees that concerning to cystic lesions and tumors associated with the impacted teeth, the incidence of dentigerous cyst is the highest among all the other pathologies ranging from about 70% to 100%. The percentage of periodontal pathogens caries in the second molar and incidence of ameloblastoma, odontoma, odontogenic keratocyst (OKC), paradental cyst, fibrosarcoma, etc., are much less. Salehinejad et al. reported that the recurrence of glandular odontogenic cyst of mandible associated with an impacted third molar, which was diagnosed radiographically as dentigerous cyst.  Patil in 2013  found out through a retrospective study that 69.7% of impacted third molar in western Indian population with a radipographically normal follicular space were associated with pathologies when subjected to histologic examination,  Joshi et al. concluded through their study in 2013 that radicular cyst is more common in maxilla which goes unnotified most of the tissues. 
| Aim|| |
The aim of this study was to determine the incidence of the development of pathology associated with impacted third molars in those patients who were evaluated for third molar surgery-a therapeutic prophylactic and an incidental finding.
| Methodology|| |
In a 6 years long study in the period 2008-2013. The study sample of 70 cases in Chennai associated with pathologies, which were sent for histopathological examination out of 2778 surgically treated impacted mandibular third molar teeth were analyzed in this study. Data concerning to the age of the patient, sex of the patient and system site of impaction, angulation of the impacted teeth and clinical assessment records of those patients whom were evaluated for their third molars were collected and systemically reviewed.
All patients had undergone a clinical assessment with a case history proforma, which comprises the details of clinical examination that was designed to have a methodological recording of the observations and investigations that were carried out.
Radiographical assessment included, intraoral periapical radiograph and in some cases orthopantomogram's were taken
All impacted teeth were classified based on Winter's classification, after which the conventional third molar impaction removal technique was followed under local anaesthesia (LA), periapical tissues were curetted and sent for histopathological examination and follow-up on the 6 th day with suture removal was done.
All patients who were evaluated for the surgical removal of their impacted mandibular third molars, including symptomatic and asymptomatic third molars and all type of impactions irrespective of the positions.
Medical status-patients with no systemic illness
Treatment findings included therapeutic, prophylactic as well as incidental findings of pathology associated with impacted mandibular third molar.
- Nonimpacted third molars other impacted teeth
- Systemic illness
- Medically compromised patients
- Impacted mandibular third molars with other impacted teeth
- Patients unwilling for data collection procedures.
Surgical site of impacted mandibular third molar region was irrigated with betadine and saliva and prepared for the surgical procedure. Infiltration is placed in addition to block anesthesia. Crevicular incision with lateral divergence of posterior extension to prevent lingual nerve damage. Mucoperiosteal flap reflection done with ohms periosteal elevator and Howartz periosteal elevator for accessibility and visualization. Limit of flap reflection is external oblique ridge. A straight handpiece with adequate speed and torque is used to remove bone from occlusal aspect of tooth with copious saliva irrigation. Bone guttering is done up to cervical line, buccal and distal aspect buccal cortical plate should be removed minimally. In horizontal impaction, crown is sectioned from the roots in a vertical plane. In vertically impacted teeth, the distal aspect of the crown is sectioned and removed first. In the case of distoangular impaction it is better to section the distal portion of the crown or complete crown in a horizontal plate and then removed. After removal of impacted teeth proper and adequate debridement should be done. Rounder, bone file and bur should be used to smoothen any sharper bony edges. Irrigation was done with betadine and saline. Primary closure was 3-0 silk was performed.
Histopathological staining procedure
In our study, the tissues were erupted and fixed in 10% formalin, processed by the paraffin embedding technique and cut into slices of 3-7 in thickness and montage on slides stained with hematoxylin and rosin stains and viewed under a light microscope.
| Results|| |
In our 6 years study within the period 2008-2013 on the assessment of incidence of pathologies associated with impacted mandibular third molars in 2778 patients out of which 70 cases reported pathology associated with the impacted mandibular third molars.
Among the 70 cases of patients that had pathologies associated with impacted mandibular third molars, 61.4% of the cases were reported as cysts and tumors and 38.6% of the cases had chronic inflammatory reaction, including two cases with normal dental follicle. Patients with the follicular space < 2.4 mm also exhibited pathology. 61.4% patients were evaluated for mandibular third molar surgery were symptomatic, 27 patients were asymptomatic. The peak incidence of pathologies associated with mandibular third molars occurred between the age group 20 and 30 years of life and lowest incidence of pathology 10% occurred in the oldest age group of patients. There was a male predominance. The most common site of impaction was found to be the left side of mandible and most common impactions was found to be vertical and distoangular impactions.
| Discussion|| |
The rising incidence of impacted teeth and their influence on the dental arches have long been of concern to the oral surgeons. Third molars are usually the last to erupt and the most commonly impacted tooth ,, Stathopoulos stated that there has been much discussion in literature regarding the prevalence of impacted mandibular third molars and its removal in spite of it being asymptomatic,  Haug et al. proved that removal of impacted teeth that are symptomatic is for certain the best choice of treatment  the dilemma exists in the early diagnosis of a small pericoronal radiolucency around the crown of an unerupted tooth and whether the majority of the asymptomatic impacted mandibular third molars can be retained in a reasonable state of health as individual age ,,,, dental follicular tissues frequently have been confused with odontogenic tumors by pathologists as well as clinicians.  The aim and objective of our study was to determine the incidence of pathology associated with impacted mandibular third molars in those patients who were surgically treated for their impacted teeth, emphasizing the need for histopathological examination of the curretted tissue from the extraction socket if any were present, to discuss whether the asymptomatic third molars are to be retained or prophylactic removed and to emphasize certain. Relevant tissue pertaining to the prophylactic removal of asymptomatic third molars in our study we have evaluated 2778 patients for their impacted mandibular third molars with proper clinical assessment and radiographic investigation. After the surgical removal of these teeth, curettage was done, and the curetted soft tissue were sent for histopathological examination.
In our study, 70 cases out of 2778 case were sent for histopathological examination. Out of 70 cases, 43 cases reported incidence of cyst and tumors. And 25 cases were reported as chronic inflammatory reaction and two cases of normal dental follicle.
The incidence of cysts and tumors occuring around impacted third molars differ gently and was reported to be low in literature ,,, in our study the incidence of pathology around impacted third molars in reported to be 1.79% with a 1.54% incidence of cyst and tumors alone. In our study, the incidence of dentigerous cyst associated with impacted third molars was 24.1% ameloblastoma 15.7%, OKC - 14.3%, radicular cyst 5.7%, two cases of squamous cell carcinoma [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6].
In a radiograph, the dental follicular sac surrounding the tooth is interpreted as pericoronary radiolucency and the width of this radiolucency is of utmost importance to determine the difference between a normal and abnormal dental follicle.  The follicle space is considered normal, is the size of the follicle is < 2.5 mm radiographically ,,, Sthepen et al. showed the probability of a cyst to exists in a follicular space of 2.5 mm radiographically, ,, in our study the impacted mandibular third molars having a follicular size measuring 2.4 mm and less radiographically also exhibited pathology which emphasized the need for histopathological examination apart from just clinical and radiographic examination.
| Conclusion|| |
As per literature our study also found out that the incidence of cysts and tumors occurring around mandibular impacted teeth are low. However, the follicular space associated with the impacted mandibular third molars below 2.4 mm in our study also reported pathology which was considered as normal follicular tissue according to the literature. This was found out once the tissues samples were sent for histopathological examination, thereby proving only clinical and radiographic examination is not sufficient to detect the pathologies associated with the impacted mandibular teeth keeping in mind the major problems associated third molars with retention of such impacted teeth may cause serious pathologies and increase in risk of postoperative complication rates if not treated at an early age and on the basis of prevention is better than cure policy, prophylactic removal of impacted mandibular third molars at an early age, symptomatic or asymptomatic is considered a better treatment modality.
| References|| |
Glosser JW, Campbell JH. Pathologic change in soft tissues associated with radiographically 'normal' third molar impactions. Br J Oral Maxillofac Surg 1999;37:259-60.
Salehinejad J, Saghafi S, Ghazi N. Glandular odontogenic cyst associated with an impacted tooth. J Dent Mater Tech 2013;2:99-103.
Dodson TB. How many patients have third molars and how many have one or more asymptomatic, disease free third molars? J Oral Maxillofac Surg 2012;70:4-7.
Patil S. Prevalence and type of pathological conditions associated with unerrupted and retained third molars in the western Indian population. J Craniomaxillofac Dis 2013;2:3-4.
Joshi NS, Sujan SG, Rachappa MM. An unusual case report of bilateral mandibular radicular cysts. Contemp Clin Dent 2011;2:59-62.
Sheik MA, Riaz M, Shafiq S. Incidence of distal caries in mandibular second molars due to impacted third molars-A clinical and radiographic study. Pak Oral Dent J 2013;32:364-70.
Bagheri SC, Khan HA. Extraction versus nonextraction management of third molars. Oral Maxillofac Surg Clin North Am 2007;19:15-21, v.
Hazelkorn HM, Macek MD. Perception of the need for removal of impacted third molars by general dentists and oral and maxillofacial surgeons. J Oral Maxillofac Surg 1994;52:681-6.
Stathopoulos P, Mezitis M, Kappatos C, Titsinides S, Stylogianni E. Cysts and tumors associated with impacted third molars: Is prophylactic removal justified? J Oral Maxillofac Surg 2011;69:405-8.
Haug RH, Abdul-Majid J, Blakey GH, White RP. Evidenced-based decision making: The third molar. Dent Clin North Am 2009;53:77-96, i×.
Friedman JW. The prophylactic extraction of third molars: A public health. Am J Public Health 2007;97:1554-9.
Duarte BG, Assis D, Ribeiro-Júnior P, Gonçales ES. Does the relationship between retained mandibular third molar and mandibular angle fracture exist? An assessment of three possible causes. Craniomaxillofac Trauma Reconstruction 2012;5:127-135.
Haddad AJ, Talwar RM, Clokie CML. The importance of recognizing pathology associated with retained third molars. J Can Dent Assoc 2006;72:41-5.
Yildirim G, Ataoglu H, Mihmanli A, Kiziloglu D, Avunduk MC. Pathologic changes in soft tissues associated with asymptomatic impacted third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:14-8.
Güven O, Keskin A, Akal UK. The incidence of cysts and tumors around impacted third molars. Int J Oral Maxillofac Surg 2000;29:131-5.
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 Radiol Endod 2006;102:448-52.
Adaki SR, Yashodadevi BK, Sujatha S, Santana N, Rakesh N, Adaki R. Incidence of cystic changes in impacted lower third molar. Indian J Dent Res 2013;24:458-65.
Saravana GH, Subhashraj K. Cystic changes in dental follicle associated with radiographically normal impacted mandibular third molar teeth. Br J Oral Maxillofac Surg 2008;46:552-3.
Wali GG, Sridhar V, Shyla HN. A Study on Dentigerous Cystic Changes with Radiographically Normal Impacted Mandibular Third Molars. J Maxillofac Oral Surg 2012;11:458-65.
Stephens RG, Kogon SL, Reid JA. The unerupted or impacted third molar-a critical appraisal of its pathologic potential. J Can Dent Assoc 1989;55:201-7.
Yadav M, Meghana SM, Deshmukh A, Godge P. The wisdom behind third molar extraction: A clinicopathologic study. Int J Oral Maxillofac Pathol 2011;2:7-12.
Kaushal N. Is radiographic appearance a reliable indicator for the absence or presence of pathology in impacted third molars?. Indian J Dent Res 2012;23:298.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]