CHAPTER II

LITERATURE REVIEW

A. Literature Review

1. Impaction

a. Definition

Impacts are teeth whose eruption paths are normally blocked or blocked,

usually by adjacent teeth or pathological tissue. Impacts are estimated by

clinical when the antagonist tooth has erupted and can almost be ascertained if

the tooth resting on the other side has erupted (Pederson, 1996).

The term impacted means a part or all of an unerupable tooth

perfectly into the occlusal plane, due to obstruction by the adjacent teeth,

bone, and surrounding soft tissue. Impacted teeth can also occur due to

the evolutionary process of decreasing jaw size as a result of changes in behavior

and diet in humans. Several factors are suspected as well

impact, including caries on the distal surface of the second molar, pericoronitis, cysts,

tissue hyperplasia or local infection (Amanat, et al., 2014).

Other studies have shown that impacted teeth are also due to factors

genetics, endocrinological disorders, palatal clefts, radiation, supernumerary teeth,

late or loss of root development, trauma, early extraction, position

ectopic, or the presence of an odontogenic tumor. Impacted teeth can also make this easier

food trapped around the teeth and surrounding soft tissue, so the patient

having trouble cleaning it, as well as resulting in easy teeth

suffer from caries and often feel sick (Bourzgui, et al, 2012)

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b. Etiology of Impaction

Impacts of third molars can occur due to several factors, among others

other tissues around the teeth that are too dense, the persistence of the milk teeth, the loss of the teeth

too early milk, no room for the teeth to erupt, and the jaw too

narrow due to imperfect growth of the jawbone. (Chandha and

Zahbia, 2007). Impaction usually refers to a tooth that is erupted by

something because it is blocked, so that the tooth cannot come out completely

achieve normal occlusion within the alignment of the teeth.

In addition, the cause of impaction can be due to circumstances

local and rare circumstances (Kresnananda, 2014).

1) Local conditions:

a) The irregular position of the teeth in the arch of the jaw.

b) The pressure on the tooth is a result of the neighboring teeth.

c) The existence of diseases that cause bone necrose due to

the resulting inflammation or abscess.

d) Chronic and persistent inflammation that can cause

thickening of the surrounding mucosal tissue.

e) Premature loss deciduous teeth which can result in missing or

reduced space for replacement permanent teeth.

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2) The systemic state

a) Causes prenatal

Hereditary (descendants) and miscegenation ( mixed race)

b) Causes postnatal

All the conditions that can interfere with the child's growth,

such as diseases: anemia, tuberculosis, endocrine gland disorders, and

malnutrition.

Rare circumstances:

a) Cleidoncranial sausage a rare congenital state,

where there is a visible ossification defect of the skull, loss

part or all of the clavicle bone, the permanent teeth are not erupted,

and there is rudimentary supernumerary teeth.

b) Oxycephali a state that looks like a tapered head

cone. In this situation there is a disturbance in the bones of the head.

c) Progeria Childish body shapes are indicated by

small stature, absence of pubic hair, wrinkled skin, hair

grayish in color but the face, attitude and behavior are like

parents.

d) Achondoplasia Hereditary, there are congenital disorders of the skeleton

resulting in dwarfism ( the condition of someone who is deprived

growth below normal).

e) Cleft palate Congenital, caused fissures on the palate

existence defect or defects at embryonic time growth.

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c. Impact classification

Classification of impacted teeth based on the relationship with the ramus of the mandible,

inclination and depth can be specified t based on the classification according to Pell and

Gregory, George Winter and Archer (Pederson, 1996)

1) Classification of impaction according to Pell and Gregory:

a) Based on the relationship between the mandibular and distal ramus

lower second molar.

Class I: The room available was adequate for the size

mesiodistal crown of the lower third molar

between the ramus of the mandible and the distal surface of the tooth

lower second molar.

Class II: Space between the distal surfaces of the second molar

lower than mandibular ramus and smaller than

mesiodistal size of the crown of the third molar

under.

Class III: All or most of the third molars are present

in the mandibular ramus.

b) Based on the relative depth in relation to

cervical line of the mandibular second molars.

Position A: The highest part of the third molar is at the level

occlusal line.
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Position B: The highest part of the third molar is below

occlusal line but still higher than line

cervical second molars.

Position C: The highest part of the third molar is below

cervical line of the second molar.

2) Classification of impaction according to George Winter:

Based on the long axis of the tooth or the position of the impacted third molar

against the second molar. These tooth positions include:

a) Mesioangular (oblique to mesial)

The lower third molar was tilting against the tooth

second molar in a mesial direction.

b) Distoangular (tilted distally)

The long axis of the lower third molar points distally

or posteriorly away from the second molar.

c) Vertical

The long axis of the lower third molars is in the direction

equals the long axis of the lower second molar.

d) Horizontal

The long axis of the lower third molars flattens out

horizontal to the long axis of the lower second molar.

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Figure 1. George Winter's classification of impactions

d. Growth Pattern of the Lower Third Molar

The lower third molars are the last teeth in the mandibular arch and

eighth gear from the midline or midline. This mandibular third molar

assist the second molars in their function. This tooth has a more shape

small and not very well-developed. Mandibular third molar

has many variations and anomalies in shape and position such as impaction.

The chronology of the growth of the third molars, namely:

a) The initiation stage, occurs at the age of 3.5 - 4 years. Step

initiation is the beginning of the formation of a tooth bud (bud)

of the oral epithelial tissue.

b) Calcification begins, at the age of 8-10 years

c) Forming a crown, at the age of 12-16 years.

d) Eruption stage, at the age of 17-21 years.

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e) Root formation is complete, occurs at the age of 18-25 years

The lower third molars were calcified at 9 years of age and erupted

full at the age of 20. The process of complete root formation occurs at the age of 22

year. With the removal of the third molar, the active eruption of the tooth is completed

fixed (Itjingningsih, 2012)

e. Prediction and Measurement Methods of Third Molar Space Availability

Under

Mercedes, et al. 2014 explain about prediction and measurement methods

impact on the mandibular third molar:

a) Olive Basford method: predicting third molars with

divides the available space by the width of the distal mesio more

lower in the third molar. Measurement of the ratio of space to width

can be determined by dividing between the available space

(AB) with the mesiodistal width of the lower third molar

(CD). The occlusal plane as a line drawn through the ends

the top of the first premolar and the cups of the second molar. A is

a point in the occlusal plane that is perpendicular to the distal to the crown

second molar. B is the intersection between the occlusal plane and

anterior border of the ramus of the mandible. C and D mark the width

mesiodistal maximum third molar.

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Figure 2. Olive-basford's method ( Mercedes, et al 2014)

b) Olmos' method: assesses the inclination of the molar angle

all three lower jaws formed by tangents

through the occlusal surface of the mandibular third molar

and tangents through the occlusal surface of the premolars

first, second premolar, first molar, and second molar.

This method determines that if the angle is less than or

equal to 32 ◦, possible molar eruption

third. Angle measurement is determined using an arc

degrees on panoramic radiographs (Mercedes, et al., 2014).

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Figure 3. Olmos's method ( Mercedes, et al., 2014)

c) Shieller method: this method uses radiography

panoramic view by looking at the inclination of the occlusal surface

third molar measured by connecting the surface

occlusal of the second molar.

a. Vertical : if the angle is between 0º to 10º.

b. Mesioangular: when the angle is between 11º to 70º.

c. Distoangular: when the angle is between 11º to 70º.

d. Horizontal : if the angle is more than 71º.

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2. Panoramic Radiography

a. Definition

Panoramic radiographs are examinations to obtain images

teeth extensively from the jaw. The part that can be seen through radiographs

Panoramic is the condition of the teeth, jawbone structure, and radiographs

panoramic view can also be used to evaluate the occurrence of trauma to the jaw, location

third molar, presence of lesions, development of dentition, condition of the patient with

edentulous, temporomandibular joint, and the development of other dental anomalies

(Gupta, et al ,, 2011) .

In dentistry, panoramic radiography is one method

data about the tooth and surrounding tissue. Use

radiographs are performed for supporting examinations in determining the diagnosis and

a proper treatment plan for a dental disease or disorder

(Booshehri, et al., 2011).

Panoramic radiographs are also recommended for pediatric patients, patients

physical disabilities or patients with reflex disorders (Ramesh, et al., 2011) Photo

panoramic also known as panorex or orthopantomogram which is very

famous in dentistry for its simple technique, the whole picture

teeth and jaws with low radiation doses (Whaites, 2003).

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b. Panoramic radiograph indication

According to Whites (2003), there is a selection of cases that require description

panoramic view in diagnosis including:

1) Looking at the alveolar bone, there is a pocket of more than 6 mm.

2) The presence of bone lesions or the size of the position of the impacted teeth

blocking the intraoral image.

3) Seeing the condition of the teeth before planning surgery. Not

recommended as a routine photo to see the progress of the eruption

third molar.

4) Knowing the presence or absence of fractures in all parts

mandible.

5) Dental implant treatment plan to look for vertical height.

6) Maintenance plan orthodontic it takes to know

the state of the teeth or tooth seeds.

c. The advantages and disadvantages of panoramic radography

According to Whaites (2003), panoramic radiographs have advantages

deficiency. The advantages of panoramic radiography are:

1) X-rays of all the bones of the face and teeth.

2) Low radiation dose to patient.

3) Make it easy to examine the patient.

4) Can be used on patients who cannot open their mouths.

5) Takes less time to take X-rays

about 3-4 minutes.

Disadvantages of panoramic radiography:

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1. Radiographs cannot provide clear anatomical details

such as periapical intraoral radiograph.

2. It is not useful for detecting small, structural lesions

true of marginal periodontium or periapical disease.

d. Types of panoramic radiographs

1) Conventional radiograph

Conventional radiograph or commonly known as Screen film

radiography (SFR) is still used more widely than digital radiographs (Bansal,

2006). The processing or printing of films from conventional radiography is still characteristic

manual, which is still using fluids development and fixing. Technique which

use on conventional radiographs is quite simple, that is, by the way

dipping the film in the liquid to produce an image

radiograph (Hardianti, 2014). Conventional radiograph examination is no longer

too domineering. This is due to the limited potential for dose reduction

for patients, the film image that cannot be changed after the occurrence of printing,

and is not compatible in image archiving (Bansal, 2006). The advantages of

Conventional radiographs are relatively inexpensive. Disadvantages of

This conventional radiograph is of poor accuracy and dosage

tall one.

2) Digital Radiograph

Modern radiography or digital radiography is a powerful tool

produces images using a sensor instead of film radiography, and the results

directly visible through the monitor. Much lower radiation dose than
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conventional, image processing is faster, and images can be edited to suit them

studied in detail is one of the advantages of digital radiographs

(Accorsi, et al., 2011).

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B. Conceptual framework

Patient at RSGM
UMY experienced
impacted third molars

Radiograph

IntraOral ExtraOral

Panoramic

Teeth Bone
Jaw

Impaction Classification

Figure 5. Concept Framework