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Dear
Editor-in-Chief
Jurnal Radiologi Dentomaksilofasial Indonesia (JRDI)
Herewith I'm sending the file of our original manuscript entitled as below for consideration of publication in the
Jurnal Radiologi Dentomaksilofasial Indonesia (JRDI) as a full article.
Type of article ORIGINAL RESEARCH ARTICLE
Full title of the Proximal Caries of Second Molars due to Impaction of Mandibular Third Molars
manuscript (English) Through Panoramic Radiographic Observations
Author(s) 1*Ellyonord Diana Bosawer, 2Yunita Savitri, 3Otty Ratna Wahyuni
Name of the Author(s) should be written in their FULL NAME without any title or degree, must
NOT be abbreviated, and it is sorted in sequence using number in superscript in front of each
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text bold for the corresponding author.
Author institution(s) 1Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Universitas

Airlangga, Surabaya, Indonesia, 60132
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and postal code in order of the author's number above.
Corresponding Email: ellyonord.diana.bosawer-2016@fkg.unair.ac.id

author’s contact
Telephone: 081354063406
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TITLE
Proximal Caries of Second Molars due to Impaction of Mandibular Third Molars through
Panoramic Radiographic Observations
ABSTRACT
Objectives: To determine the distribution of proximal caries in second molars due to impacted mandibular third
molars through panoramic radiographic observations. Materials and Methods: In this study, 1386 secondary
data were used for panoramic radiography at Universitas Airlangga Academic Dental Hospital in 2018 to 2021.
There were 157 samples observed based on the Pell and Gregory classification. Results: The patterns of third
molar impaction according to Winter’s classifications at Universitas Airlangga Academic Dental Hospital in 2018
to 2021 are mostly Mesioangular (46,7%), in 2018 to 2021 the mostly are Mesioangular (46.7%), with the
prevalence of proximal caries cases of mandibular second molars due to impaction of mandibular third molars
(67.25%).
Conclusion: The pattern of mandibular third molar impaction based on Winter's classification has the highest
frequency in the mesioangular position. The prevalence of cases of proximal caries or distal caries in second
molars due to impaction of mandibular third molars is 67.25%
Keywords: Mandibular third molar impaction , Winter classification, Panoramic Radiograph, Proximal Caries of
the Mandibular Second Molar
INTRODUCTION
Impacted teeth are often found in dentistry. People generally understand that wisdom teeth are
located at the very back of the jaw. Impacted teeth are teeth that experience interference with the complete
growth process. This can be caused by several factors, one of which is the abnormal position of the tooth germ,
so that the tooth cannot erupt properly. Based on its distribution, impacted teeth often found in third molars
and more in women than men.1 The frequency of eruption disorders is highest in the third molars, both in the
upper and lower jaws, followed by the maxillary canines. This is because the third molars are the last teeth to
erupt, so there is often not enough space available for eruption.2,3 Based on the data obtained, the frequency of
third molar impaction varies substantially between different populations ranging from 18% to 70%.3-7
Morover, the causes of impacted teeth can be grouped into local, systemic and bad habit causes.
Impacted teeth can also be caused by primary factors including genetic factors, trauma to the primary teeth,
rotation or turning of the tooth buds, premature loss of primary teeth and eruption of canine teeth in the cleft
palate, as well as secondary factors including endocrine disorders, vitamin D deficiency and febrile disease.8-10
In addition, the impact of impacted teeth can include neuralgic pain, pathological resorption of adjacent teeth,
formation of follicular cysts, pericoronitis, danger of jaw fracture due to jaw weakness, crowding of anterior
teeth due to anterior pressure of impacted teeth, periostitis (impact of tissue inflammation around the bone
called the periosteum), and neoplasms.11,12
Meanwhile, one of the most common pathological abnormalities caused by impacted mandibular third
molars is distal caries in the mandibular second molars. The development of caries in mandibular second molars
is influenced by the impaction pattern of mandibular third molars.13,14 One of the classifications used for
impacted third molars is George Winter, who classifies impacted third molars based on the relationship of the
impacted tooth to the long axis of the mandibular second molar. Winter classifies impacted third molars as
mesioangular, vertical, horizontal, distoangular, transverse, and inverted.15 In this study, the prevalence of using
secondary data in the form of panoramic radiography from 2018 to 2021 was 8.83% of 1386 data.
In previous research conducted by Muhamad and Nezar (2016) in Israel, it was shown that of a total of
1,706 patients who came and underwent panoramic radiography examinations, there was almost the same
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prevalence of third molars on both sides of the left (47.8%) and right (52,2%). This research also shows that
mesioangular impaction (50%) is the most common type of impaction. The least common type of impaction is
inverted (0.3%). The prevalence of impacted mandibular third molars in this study was 19.2%. Several studies
also report that the average prevalence of impacted mandibular third molars is from 9.5% to 50%, higher in
Western regions such as the European Union and Africa.15 In addition, the results of research conducted by
Alsaegh et al., (2022) showed that the presence of distal caries in mandibular second molars due to impaction
of mandibular third molars was 126 (18.36%) of the mandibular third molars impactions have associated carious
lesions. Among them, 102 (14.86%) showed distal caries in the mandibular second molar adjacent to the
mandibular third molar, and 24 (3.49%) showed caries in the impacted mandibular third molar. Distal caries in
second molars is often associated with impacted third molars which cannot be seen clinically, so supporting
examinations, namely panoramic radiography, are needed to diagnose cases of impacted teeth. Panoramic
radiography is the radiographic examination that is currently most frequently used for cases of impacted third
molars, and is the first complementary examination in the exploration of third molars and related
pathologies.13,16,17 Panoramic radiography is a simple extraoral procedure that images the maxillary and
mandibular areas on one piece of film.
Panoramic radiography is a simple extraoral procedure that images the maxillary and mandibular areas
on one piece of film. The advantages of panoramic include all tissue over a large area that can be depicted on
film, including facial bones and teeth, the image is easy for patients to understand and is a learning medium,
suitable for use in patients who are sensitive to the feeling of vomiting. Apart from that, the advantage of
panoramic radiology is that it can cover the entire maxillomandibular area so that it can display impacted molars
in more than one region.18
MATERIALS & METHODS

This study is an observational study using secondary data in the form of panoramic radiographs totaling
1386 secondary data samples. The study population was patients with impacted teeth who underwent
panoramic radiography examinations in the period January 2018 to December 2021 at the Airlangga University
Academic Dental Hospital. The sampling method used was purposive sampling, which is based on predetermined
criteria, namely patients who have impacted mandibular third molars; the apical part of the third molar teeth is
perfectly formed; the results of the panoramic radiography quality evaluation are good. This research was
conducted at the Airlangga University Academic Dental Hospital, Surabaya and was carried out for
approximately 2 months from July to August 2023. The instruments used were secondary data in the form of
panoramic radiographs, a laptop, and IBM SPSS version 26 software (IBM Corporation, USA) . This research has
been registered with the Ethics Committee of the Airlangga University Academic Dental Hospital with a
certificate of ethical suitability Number: 25/UN.9.3/Etik/PT/2023.
The workings of this study are (1) submission of research ethics and clinical licenses. (2) Collecting
secondary data on panoramic radiography samples from patients at Airlangga University Academic Dental
Hospital for 2018 – 2021 according to the required criteria. (3) Sample selection is based on research criteria. (4)
The selected data is collected into one folder on the laptop. (5) Observation of secondary data on panoramic
radiography by three researchers based on Winter's classification accompanied by proximal caries in the second
mandibular molar.
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Figure 1. Winter classification
RESULTS
The ICC reliability test for angulation of the third molar towards the mandibular second molar obtained
a value of 0.979 or close to one, meaning that the reliability and validity between researchers is close to perfect
or very good. The ICC reliability test for third molar bone depth obtained a value of 0.888 or close to 1, so the
reliability between researchers was close to perfect or very good.
Research data collected from the Airlangga University Academic Dental Hospital from 2018 to 2021
obtained 1386 panoramic radiography data. Then a selection was carried out based on the inclusion criteria by
the researcher with 2 supervisors, then 157 samples were obtained for the inclusion criteria of cases of impacted
mandibular third molars accompanied by proximal caries of the mandibular second molars in patients at the
Airlangga University Academic Dental Hospital. The prevalence of caries proximal to the mandibular second
molar due to impaction of the mandibular third molar was 67.25%.
Table 1. Distribution of types of mandibular third molar impaction based on the angulation of the mandibular
third molar relative to the mandibular second molar
Type of Impaction Frequency (%)
Mesioangular 107 46,7
Distoangular 8 3,5
Vertical 19 8,3
Horizontal 88 38,4
Transversal 5 2,2
Inverted 2 0,9
Total 229 100
Table 2. Distribution of impacted teeth of mandibular third molars according to Winter based on their angulation
accompanied by proximal caries of mandibular second molars
Type of Impaction Frequency (%)

Mesioangular 87 57,2
Distoangular 0 0
Vertical 8 5,3
Horizontal 55 36,2
Transversal 2 1,3
Inverted 0 0
Total 152 100
Sample panoramic photo of proximal caries of the second molar due to impaction of the mandibular third
molar on panoramic radiography
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(a) Mesioangular; (b) Horizontal; (c) Vertical; (d) Transverse

Prevalence of proximal caries due to impacted mandibular third molars
To calculate the prevalence of cases of proximal second molar caries caused by impacted third molars, the
formula is used
𝑇𝑜𝑡𝑎𝑙 𝑐𝑎𝑟𝑖𝑒𝑠
Prevalence = Total impacted teeth X 100%
154
Prevalence = 229
X 100%
Prevalence = 67,25 %
Cases of mandibular third molar impaction based on the angulation of the mandibular third molar
towards the mandibular second molar were more numerous in the mesioangular type of impaction with 107
cases with a percentage of 46.7%, followed by horizontal with 88 cases with a percentage of 38.4%, vertical with
19 cases with a percentage of 8.3%, distoangular in 8 cases with a percentage of 3.5%, transverse in 5 cases with
a percentage of 2.2% and inverted in 2 cases with a percentage of 0.9%.
Meanwhile, for the mandibular third molar impaction pattern based on the angulation of the mandibular
third molar towards the mandibular second molar accompanied by caries proximal to the second molar, the
highest results were obtained, namely mesioangular with 87 cases with a percentage of 57.2%, followed by
horizontal with 55 cases with a percentage of 36.2%. However, there were no proximal caries found, namely
inverted and distoangular.
DISCUSSION
This research was conducted at Universitas Airlangga Academic Dental Hospital because it is one of the
dental teaching hospitals that focuses on dental and oral health services. Universitas Airlangga Academic Dental
Hospital also has a Dental Radiology service which is a supporting examination for many cases in the field of
dentistry, one of which is examination of impacted teeth and caries. This information about the pattern of
mandibular third molar impaction is useful for educational purposes and can also be useful for improving the
quality of Universitas Airlangga Academic Dental Hospital services at Airlangga University. This research at
RSGMP Airlangga University used secondary panoramic radiography data samples from patients from 2018 to
2021, and after selection, 157 (8.83%) samples out of 1386 met the criteria.
Impacted teeth are teeth that fail to grow into the dental arch during normal growth or teeth that
cannot erupt completely or partially because they are covered by bone or soft tissue or both.1,19 The frequency
of eruption disorders is highest in third molars, both in the upper and lower jaws. This is because the third molars
are the last teeth to erupt, so there is often not enough room available for them to erupt.2,20 Previous published
studies have reported the prevalence of impacted teeth ranging from 6.9 to 76.6%.21 Many studies conducted
in various parts of the world have reported a variable prevalence of impacted third molars, ranging from 16.7%
to 68.6%.14,22-24 This study also found that cases of unilateral third molar impaction were higher (53.3%) than
bilateral (46.4%). These findings are in line or consistent with other research such as Kumar et al, 2017 who
found that unilateral cases occurred more often. This may be caused by racial, ethnic, or genetic factors.24
In this study, the results of mandibular third molar impaction were mesioangular (47.3%), distoangular
(3.5%), vertical (8.8%), horizontal (37.6%), transverse (2.2%) , and inverted (0.6%). Data shows that the most and
least impactions occur in impaction patterns with mesioangular (47.3%) and inverted (0.6%) angulation. The
results of this study are close to the results of research conducted by Muhamad and Nezar (2016) in Israel which
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showed that mesioangular impaction (50%) was the most common type of impaction. The least common type
of impaction is inverted (0.3%). Prevalence of impacted mandibular third molars in this study it was 19.2%.
Several studies also report the average prevalence of impacted mandibular third molars.15
Another study was also conducted by Jaron and Trybek, 2021 which showed that the most common
type of impaction was mesioangular impaction (52.56%)25 A similar report was also confirmed in 2016 by Nagaraj
and co-authors (Nagaraj et al., 2016) who presented mesioangular impaction in 47.1% of patients, as well as
many other researchers.5,6,24,26 Padhye et al. presented an analysis of pantograph radiographs of 1200 subjects,
and 33.33% of subjects showed mesioangular impaction according to Winter.28 Kumar also et al. observed the
prevalence of mesioangular impaction (52.89%) cases in the Eritrean population.24 This study also showed that
caries was caused by impacted mandibular third molars. Caries is mentioned as one of the common pathological
features associated with mandibular third molars and teeth nearby. There is an opinion that the position and
inclination of the teeth play a major role in the process of caries development.29,30
Partially erupted teeth do not participate in the chewing process so they are more favorable for
bacterial accumulation than fully erupted teeth.31 Because the lower and upper third molars are the most
commonly covered teeth, pericoronitis is associated with poor oral hygiene and lower self-cleansing areas
against accumulated food and microorganisms cannot be cleaned through normal brushing and flossing, leading
to the development of caries. Over the past 40 years, the incidence of impacted teeth has increased in the
population different.32
In this study, it was found that the type or pattern of mandibular third molar impaction that most
commonly causes distal caries in mandibular second molars is mesioangular angulation (57.2%), then followed
by impacted horizontally angulated mandibular third molars (36.2%). These results are in accordance with
previous research conducted by Mohammed Amjed Alsaegh (2022) who found that mesioangular impaction was
associated with distal caries on the second mandibular molar adjacent to the impacted third molar, followed by
distal caries on the second mandibular molar due to horizontal impaction. These findings are consistent with
previous studies that found equivalent results.13,24,33 This result is due to the mesial peak of the mesioangular
impacted third molar touching above the cemento enamel junction so that the space and contact point between
the second molar and the impacted third molar are inadequate for daily oral cleaning which results in distal
proximal caries lesions on the teeth. second molar.
A previous study showed that mesioangular impacted mandibular third molars grow in the
mesioangular direction and their apex is in contact with the surface distal to the mandibular second molar and
presses on the distal surface of the mandibular second molar, causing distal caries on the mandibular second
molar.33 Ozec et al. also reported that the contact point at the cemento enamel junction of the second molar
had a statistically significant influence on the development of distal caries.33 Research conducted by (Haddad et
al., 2021) found that tooth angulation has a significant influence on the development of distal caries in adjacent
teeth. In the study (Haddad et al., 2021), 74.4% of all distal caries occurred in the presence of impacted
mandibular third molars with mesioangular and horizontal angulation, in decreasing order of frequency.34
Meanwhile, in this study, no proximal caries was found in the mandibular second molar due to
impaction of the mandibular third molar with distoangular angulation. This finding is in line with research by
(AlHobail et al., 2019) which also found that distoangular impaction did not show a significant relationship with
the incidence of surface caries distal to the second molar.35 In fact, distal carious lesions in second molars are
found mostless common in distoangular impaction. Therefore, previous studies reported distoangular impaction
as a protective factor against dental caries.29,35
The prevalence of distal second molar caries associated with partially or completely impacted third
molars has been reported to vary from 1% to 47%. In general, research (AlHobail et al., 2019) reported a 48.6%
prevalence of caries on the distal surface of second molars found in third molars.14,33,35,36 This research shows
that the prevalence of cases of mandibular third molar impaction which causes caries is 67.25%.
In addition, during the observation of panoramic photo samples, there were several obstacles, such as
the superimposition of second molars and third molars on several samples, causing difficulties in selecting
proximal caries.
CONCLUSION
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The total research sample included in the research criteria was 157 samples from 1386 samples based
on the Winter’s classification at Universitas Airlangga Academic Dental Hospital in 2018 to 2021 had a proximal
caries prevalence of 67.25%. The distribution of proximal caries in mandibular second molars due to mandibular
third molar impaction is mandibular third molar impaction mesioangular impaction 57.2%, horizontal impaction
36.2%, distoangular impaction 0%; vertical impaction 5.3%, transverse impaction 1.3%, and inverted impaction
0%. The prevalence of cases of proximal caries or distal caries in second molars due to impaction of mandibular
third molars is 67.25%.
The distribution of proximal caries in mandibular second molars due to impaction of mandibular third
molars is mesioangular mandibular third molar impaction 57.2%, horizontal impaction 36.2%, distoangular
impaction 0%; vertical impaction 5.3%, transverse impaction 1.3%, and inverted impaction 0%. The prevalence
of cases of proximal caries or distal caries in second molars due to impaction of mandibular third molars is
67.25%.
ACKNOWLEDGMENTS
We would like to express our gratitude towards our lecturers, family, and friends for all the support
during the process of this study.
FOOTNOTES
Conflict of interest:
The authors have no conflict of interest to declare.
Human/animal rights statement:

25/UN3.9.3/Etik/PT/2023
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Jurnal Radiologi Dentomaksilofasial Indonesia

(JRDI) ORIGINAL RESEARCH ARTICLE

Type of article ORIGINAL RESEARCH ARTICLE

Author(s) 1*Ellyonord Diana Bosawer, 2Yunita Savitri, 3Otty Ratna Wahyuni

Author institution(s) 1Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Universitas

Corresponding Email: ellyonord.diana.bosawer-2016@fkg.unair.ac.id

(Ellyonord Diana Bosawer)

MATERIALS & METHODS

Figure 1. Winter classification

Type of Impaction Frequency (%)

(a) Mesioangular; (b) Horizontal; (c) Vertical; (d) Transverse

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