IMPACTION ON AN INCREASE – WHY?

Impaction is defined as the inability of the tooth to erupt in the oral

cavity because of some barrier or obstruction in it’s path (more specifically
by a tooth or bone or soft tissues).
Any tooth may be impacted, but certain ones are more commonly
affected that the others. Thus the maxillary and mandibular third molars and
the maxillary cuspids are the most frequently impacted teeth followed by
premolars and supernumerary teeth of the third molars, the mandibular teeth
are more apt to exhibit severe impaction than the maxillary teeth.
Etiology
Inadequate space in the dental arch for eruption
The phylogenetic theory – Due to evolution, the human jaw size is becoming
smaller and since the third molar tooth is last to erupt, there may not be
room for it to emerge in oral cavity.
Mendelian theory – Here genetic variations play a major role. If the
individual genetically receives a small jaw from one of the parents and / or
large teeth from the other parent, then impacted teeth can be seen because of
‘lack of space’.
Further causes of impaction of tooth can be divided into local and
systemic factors:
Local causes:
 Obstruction for eruption
o Irregularity in position and presence of an adjacent tooth.
 Lack of space in dental arch – crowding, supernumerary teeth
 Ankylosis of primary or permanent teeth
  Non resorbing roots, over-retained or premature loss of deciduous
teeth.
 Ectopic position of tooth bud.
 Dilaceration of roots (trauma)
 Associated soft tissue / bony lesions
 Habits involving tongue, finger, thumb etc.
Systemic causes
 Prenatal cause – Heredity
 Postnatal – rickets, anemia, malnutrition
 Endocrine disorders of thyroid, parathyroid, pituitary gland
 Hereditary linked disorders – Down syndrome, Hurler’s syndrome,
Osteoporosis.

The first comprehensive inquiry into malocclusion and its causes was
by Weston Price. In 1930’s, he traveled the world to document the
nutritional habits and physical degeneration of people living on
contemporary ‘civilized’ diet. He found a significant increase in
malocclusion in societies living on contemporary diets of prepared foods.
The incidence of malocclusion amongst aboriginal people increased
after contact with commercial societies. He examined both living
populations and many collections of archeological material. This observation
gives rise to a theory widely favored among anthropologists which may be
stated as follows:
“Malocclusion arises from lack of chewing stress with the modern
processed diet. This disuse has reduced jaw growth and increased the
incidence of occlusal variation”.
 However the overall picture is not as simple as stated in the
above sentence. It is a combination of various factors. These factors are
discussed below:
1) Hominid dental system is small relative to apes and has decreased in size
over evolutionary time:
The masticatory system of great apes is larger than that of humans.
Leonard and Robertson report that the dentition of our ancestors decreased
from Australopithecus to Homo erectus, coincident with development of
stone tools and increasing consumption of meat hence decreasing
consumption of coarse vegetable foods.
Technology – stone tools – permitted our prehistoric ancestors to
hunt, kill and carve up for transport large animals. All of this was done via
tools, obviating the need for the typical carnivore adaptation – strong jaws,
sharp teeth, claws, powerful muscles for mastication etc.
2) Potential effect of primitive food processing technology
Brace et al (1991) presented a fascinating hypothesis. Analyzing the
evidence from Neanderthan sites (2,00,000 years ago) they note – ‘The
important thing to look is what was done to the food before it was eaten’. If
that can be accepted, it should follow that the introduction of nondental food
processing techniques should lead to changes in the forces of selection that
had previously maintained the dentition.
As their analysis continues, they not the following-
 The cooking of food in earth ovens can be dated back over 2,00,000
years ago.
 Meat cooked in such a fashion can become quite soft and in such
condition it requires less chewing to render it swallowable than would
be the case if it remained uncooked. In turn, this could represent the
 relaxation of pressure for maintaining teeth at the normal relationship.
The appearance of the earth oven in the archeological record, then,
should mark the time at which the dental reduction had its beginning.
 They then tie the further reduction in human dentition to the use of
pottery, which allows preparation of soups (on which one can survive
even if toothless) and allows fermentation as well.
Hence Brace et al correlate the evolutionary reduction in the
size of human dentition to universal cultural innovations. Cooking and
food processing which promoted survival and relaxed selection
pressures that favour large, robust dentition. The end result of such
selection pressure is our modern dentition, which is smaller and
weaker than our prehistoric ancestors.
The above material suggests that changes in diet and food
processing techniques relaxed the pressures for ‘robust’ dentition.
However such factors reflect but one set of selection pressures
operating of human mouth. Other factors that may impact the
evolutionary morphology of head, mouth and oral systems include;
brain size, upright bipedal posture and extremely important language
3) Increasing brain size reduces space available for oral features:
The increase in brain size increases the space required for the cranium
(brain vault). This coupled with slight postural realignments required for
bipedalism, may cause subtle but significant changes in the architecture of
the head as a whole. The shift in the center of gravity of the head caused by
increasing brain size and bipedal posture could increase selection pressures
for a smaller mouth and oral systems.
4) The influence of language on the oral system:
 Another important selection pressure acting on the human mouth and
oral systems was the development of language.
Hiiemae point out that fully developed language requires a very
flexible oral system, jaws, tongue, esophagus etc. Thus it is no surprise that
human oral system emphasizes flexibility and is quite different from that of
carnivores like cats or dogs who have no need of language and who lack
tools and must use sharp teeth and claws instead.
Selection pressures on humans due to language are unique:
Hiiemae analyzed the process of chewing and swallowing in
mammals and finds that the process is identical – except in humans. There is
a significant difference in sequence of events in humans and describes the
difference as ‘a reflection of a fundamental change’.
He notes that man is the only mammal in which communication has
become a dominant oropharyngeal activity. Speech involves the exactly
patterned modulation of the basic note emitted from the larynx. That
patterning is produced by a change in the shape of the air space in the oral
cavity and by use of a series of stops which involve the tongue, teeth and
lips.
The above suggests that the development of the unique human feature
– language – may have required changes in morphology. Shea (1992) reports
that the evolution of speech was associated with changes in skull base and
pharynx both of which indirectly impact the jaws and dental system.

Linkage of language and brain development

The human brain was capable of producing and comprehending
language which leads to evolution of mouth and throat the way they did to
facilitate language production.
 The importance of language and the advantage it provides in
communicating, co-ordinating our activities and thinking suggests that the
language itself lead to evolution of the brain.
Thus the evolution of mouth / oral systems was closely related to the
evolution of the brain via the feature of language.

To summarize
 Humans do not have claws, razor-sharp teeth or the other adaptations
found in carnivores because from the very inception we have used
technology at first in the form of stone tools – to serve the same
functions as claws, sharp teeth etc. This buffered humans from the
pressures associated with the development of features associated with
carnivores.
 Additional selection pressures on the human head came from
encephalization, bipedal posture and the development of language.

The etiology of third molar impaction

Human evolved in high dental attrition environment. Mastication of
tough food not only involved wear of occlusal surfaces but also movement
of each tooth within its alveolus, constraint by periodontal ligament. This
movement of teeth within dental arch also resulted in wear on the
interproximal surfaces. This resulted in reduced tooth diameter in mesio-
distal dimension.
The recent trend in increasing impactions does not seem to be genetic
change in humans, instead, it is, merely a response to a soft diet. Without
interproximal wear of the teeth, there simply is not enough room for third
molar. Other factors at work with modern soft diets are dental arch width –
narrower dental arches that resulted from disuse also contribute to shorter
dental arches with les space available distal to second molar.

Caries – as a cause of impaction

Again as the diet changed from coarse vegetable foods to soft sticky
diet, the incidence of caries increased. Increase in the incidence of caries has
been a major event in increasing the malocclusion which in turn gave rise to
impaction.
Increased incidence of caries activity is experienced by early loss of
deciduous teeth. A well known example is premature loss of deciduous 2nd
molar which leads to mesial migration of permanent 1st molar which in turn
results in impaction or ectopic eruption of 2 nd premolar in mandibular arch
and canine impaction in maxillary arch.
Premature loss in anterior region also leads to migration of adjacent
teeth in that space which in turn leads to malocclusion and impaction of
permanent teeth.