|Year : 2019 | Volume
| Issue : 6 | Page : 393-397
Effect of the impacted third molars on the development of temporomandibular joint (TMJ) clicking
Hussein Haleem Jasim
Department of Oral Diagnosis, College of Dentistry, University of Wasit, Wasit Province, Kut city, Iraq
|Date of Web Publication||26-Nov-2019|
Dr. Hussein Haleem Jasim
Department of Oral Diagnosis, College of Dentistry, University of Wasit, Wasit Province, Kut city.
Source of Support: None, Conflict of Interest: None
Aims and Objectives: Temporomandibular joint (TMJ) clicking has been considered as the most important clinical features of many TMJ disorders, so that the early diagnosis of TMJ clicking could be considered an important value for early treatment. The knowledge and study of the factors that have an adverse effect on the TMJ are necessary for the proper diagnosis, treatment, and prognosis of TMJ disorders. This aim of this study was to observe whether there was a relationship between the presence of impacted third molars and the development of TMJ clicking. Materials and Methods: The study was undertaken on 189 patients with bilateral maxillary and mandibular impacted third molars aged between 18 and 25 years, in regardless of genders that were referred to the radiology department of some dental centers in Baghdad for taking orthopantomograms (OPGs) from June 2017 to December 2018. The patients were examined clinically for detecting the temporomandibular clicking by using a stethoscope for hearing clicking sounds during mouth opening and mandibular excursion. Results: The statistical analysis showed that there was no significant relationship between the presence of impacted third molars and development of TMJ clicking (χ2 = 1.04; P = 0.3). Conclusion: According to this study, impacted third molars were not considered to be an effective factor in the occurrence or development of TMJ clicking or sound.
Keywords: Clicking, impaction, temporomandibular joint (TMJ), third molar
|How to cite this article:|
Jasim HH. Effect of the impacted third molars on the development of temporomandibular joint (TMJ) clicking. J Int Oral Health 2019;11:393-7
|How to cite this URL:|
Jasim HH. Effect of the impacted third molars on the development of temporomandibular joint (TMJ) clicking. J Int Oral Health [serial online] 2019 [cited 2021 Jul 27];11:393-7. Available from: https://www.jioh.org/text.asp?2019/11/6/393/271782
| Introduction|| |
Temporomandibular anatomy is considered complex. The temporomandibular joint (TMJ) is different from the other joints of the body, because the left and right sides of TMJ are connected with one bone (mandible), so one of the joints cannot move apart from the other. Condylar head of mandible and temporal bone are isolated by an articular disk that divides the joint into upper and lower joint compartments (bilateral articulation) and that considered the single merit of TMJ from other joints of the body. The upper joint compartment is located between a temporal bone and the articular disk with gliding or translator movement, whereas the lower joint compartment is located between the head of the mandibular condyle and the articular disk with a rotary or hinge movement, so it is called a ginglymo-arthroidal joint because of its ability to perform these movements. In this way, the mandible will be allowed to move into three various levels. The TMJ plays an important role in the orientation of mandibular movements as well as balancing stresses due to the daily activities as speech, mastication, and swallowing.
Temporomandibular disorders comprise disorders of the TMJ, the related muscles of mastication, and the surrounding skeletal structures. These disorders may be congenital, developmental, traumatic, inflammatory, neoplastic, and infectious. TMD was considered one of the craniofacial disturbances accompanied by pain which referred to the TMJ, jaws, and masticatory musculatures. The patient with temporomandibular disorders complained of pain, restricted movements of mandible, and sounds within the TMJ in addition to other symptoms that are often associated as ear buzzing, earache, headache, vertigo, and neck pain. Generally, temporomandibular disorders can be divided into intra-capsular (intra-articular) and extra-capsular (nonarticular). Parafunctional habits (as grinding a clenching) were commonly believed to be as extra-capsular problems.
Bollero et al. reported that the manifestation of temporomandibular disorders in women is more than two and a half times as compared to men. The more affected ages in women ranged between 40 and 50 years, while in men the affected ages ranged between 30 and 40 years.
Many studies have been conducted to monitor the effect of certain factors on the TMJ and the related structures. Luminita studied the effect of some parameters that are associated with the movement of TMJ and their effect on the morphology of teeth. Ohmi et al. studied the relation between the presence of emotional stress and TMD. Others studied the relationship between orthodontic therapy and temporomandibular dysfunction.
Dental impaction refers to a tooth that resides totally or partially embedded (unerupted) in the bone of jaw or under gingival tissue. Different causes may be behind this impaction as insufficient space for eruption, defects, pathologies, and trauma. The most common dental impactions reported were third molars. Matsuyama et al. stated that the impacted third molar in Europe is prevalent in young adults by more than 70%. Manoj et al. stated that the impacted third molars in mandible were more than twice as compared to the maxilla, and were far more common among women.
Many studies have discussed the adverse effects of impacted teeth in the jaws; Ma’aita and Alwrikat stated that many pathologies and abnormalities are often associated with impacted teeth as pericoronitis, neoplasm, periodontitis, cystic lesions, and root resorption, and can cause harmful effects on an adjacent tooth. Shervan et al. found that there was a possible relationship between embedded teeth as wisdom teeth and the development of odontogenic lesion Others confirmed that there were adverse effects of impacted third molars, Such as debilitating the angle of mandible and make it more critical to fracture., And increasing the possibility of lower arch crowding, TMJ disorders, vague orofacial pain, and neuralgias.,
The position and difficulty of impacted third molars could be an effective factor more over to their proximity to TMJ. Therefore, some authors suggested that the TMJ disorder signs are prevalent in patients referred for extractions of impacted third molars and the exacerbation of these signs is a reasonable possibility after surgical extraction of impacted third molars, because the surgery includes a prolonged period of wide mouth opening. In addition, the pressure exerted during the extraction of the impacted third molar might be another harmful factor to the close anatomical skeleton, especially the TMJ. Therefore, this study has focused on the correlation between third molar impaction and TMD signs as clicking.
| Materials and Methods|| |
The prospective study was undertaken on 189 patients. All patients selected in the study had bilateral maxillary and mandibular impacted third molars, aged between 18 and 25 years, in regardless of genders that were referred to the radiology department for taking orthopantomograms (OPGs) from June 2017 to December 2018.
The selected radiographs in the study were with bilateral maxillary and mandibular impacted except for OPG for patients with some conditions. The exclusion criteria of the study were as follows: any pathology in the jaws and dentition; patients with malocclusion or posterior teeth missing; long history of TMJ clicking; tenderness to palpation of TMJ or painful clicking; any craniofacial anomaly; patients with limitation of mouth opening; patients with dental appliances; patients with parafunctional habits such as clenching, grinding, and eating on one side of jaws; patients with previous dental surgery; patients with TMJ replacement; and patients with previous TMJ injection.
After the radiological examination, only 189 radiographs were selected; one hundred and fifty-one patients were enrolled with bilateral maxillary and mandibular partially impacted 30 molars and 38 patients were enrolled with bilateral maxillary and mandibular completely impacted third molars.
The position and angulations of impacted third molars in the study were evaluated by OPGs. The impacted third molars included in the study are varied according to the following:
- Pell and Gregory classification. It describes the position of impacted third molars in the bone to confirm whether they are Class A: not impacted, Class B: partially impacted, or Class C: completely impacted in the bone [Figure 1].
|Figure 1: A bar graph showing the distribution of maxillary and mandibular third molars position in the study according to Pell and Gregory classification (Class A: not impacted, Class B: partially impacted, and Class C: completely impacted in the bone)|
Click here to view
- Winter’s classification. It describes the angulations of impacted third molars in the bone to confirm whether they are in vertical, horizontal, mesio-angular, or disto-angular impaction and others [Figure 2].
|Figure 2: A bar graph showing the distribution of maxillary and mandibular impacted third molars angulation in the study according to Winter’s classification|
Click here to view
The patients were examined clinically for detecting the temporomandibular clicking by using a stethoscope for hearing clicking sounds during mouth opening and closing movements, including protrusive, retrusive, and lateral mandibular excursions. The clicking sounds heard from each cycle of these movements are recorded and analyzed as TMJ clicking.
| Statistical Analysis|| |
Data were analyzed using a Pearson’s chi-squared test by using the Statistical Package for the Social Sciences software (version 19). The relations between the groups were analyzed using the Pearson’s chi-squared test. The level of significance was found to be 0.05 and a value of P < 0.05 was considered statistically significant.
| Results|| |
The study included 189 patients with bilateral maxillary and mandibular impacted third molars. After clinical examination for detecting TMJ clicking, the number of cases with a recent history of TMJ clicking was 25 in patients with bilateral partially impacted third molars and in patients with bilateral fully impacted third molars were nine cases. Distribution of patient’s samples showed that the number of cases with TMJ clicking is small as compared with that without TMJ clicking in total dental impaction samples. Therefore, this may give an initial impression that both variables are independent. Hence, statistical analysis was performed here to detect whether there is a relationship between the presence of impacted third molars and development of TMJ clicking. It was conducted by using Pearson’s chi-squared test and the value of P ˂ 0.05 was considered statistically significant. The statistical analysis showed that no significant relationship was found between the presence of impacted third molars and development of TMJ clicking. With 95% confidence intervals, the population mean was found to between 86.4 and 102.4 based on 189 samples.
Confidence interval was found to be 94.5 ± 8.05 with 1degree of freedom (df). Therefore, the χ2 value was 3.841 at the significance level of P = 0.05 with 1 df, while the χ2 value (statistic) was 1.04 at the significance level of P = 0.3.
The χ2 value (statistic) was ˂3.841, so we accepted the null hypothesis for a chi-squared independence test; the two variables are independent in some population. This means that the presence of impacted third molars has no effect on TMJ clicking [Table 1].
|Table 1: Distribution of patient’s samples with bilateral partially and completely impacted third molars and the status of TMJ with and without clicking|
Click here to view
| Discussion|| |
Temporomandibular disorders are annoying to many patients because of their undesirable symptoms.
Many causes are responsible for the development of these disorders. In addition, there are many factors that aggravate the symptoms of these disorders, so studying and determining these factors is important. The study here considered the impacted third molars to be one of the possible factors that may have an undesirable effect in the development of TMJ clicking, which is considered one of the important symptoms of temporomandibular disorders. Diagnosis of these disorders still considered a challenge to many dentists due to the extensive symptoms and many causative factors of these disorders. Therefore, the diagnosis of the causes and risk factors of these disorders together will greatly help in the proper treatment.
Honda et al. concluded that the proper assessment of temporomandibular sounds may play an important role in the diagnosis and treatment of temporomandibular dysfunction. On the contrary, Kurita et al. stated that the presence or absence of clicking should not be the unique factor considered during the diagnosis of disk displacement with and without reduction and additional examinations as MRIs are needed to get a precise diagnosis that gives a detailed analysis to possible intra-articular disorders and a proper treatment later.
The aim of this study was to observe whether the impacted third molars had a relationship in the development of TMJ clicking and it was found that presence of impacted third molars had no significant effect on the development of TMJ clicking or sounds.
Thus, according this study, the impacted third molar was considered a non-exacerbated factor in the occurrence of TMJ clicking. This may be because of the possibility that there were other factors in addition to the impacted third molars may be responsible for the development of TMJ sounds or clicking in spite of the detection of some cases with TMJ clicking. Some studies agreed with this study. De Angelis et al. stated that the cause of TMJ pain or problems as clicking is more likely to be related to the recent symptoms of temporomandibular disorders rather than the presence of impacted third molars. Prinz observed several factors that are contributed in the development of TMJ sounds and these factors may cause some defects in the structure and function of the joint, such as the impact between joint components, the deformity of these components, and the changes in the quality of the synovial fluid. The impacts between the condyle and the mandibular fossa are associated with subluxation, osteoarthritic changes, and disk displacement. These conditions cause excessive friction between joint components, which in turn develop sounds. On the contrary, Barclay observed the TMJ clicking in 36% of the joints with normal disk positions. Carlsson et al. also stated that the development of clicking was more common without any sign or symptom of temporomandibular disorders.
Although the nonsignificant statistical results of this study do not report the effect of impacted third molars on the development of TMJ clicking, the study suggests that the early treatment of TMJ problems in the presence of asymptomatic impacted third molars is considered to be critical to avoid as much as possible the complications of surgical extraction of such teeth that exacerbate preexisting problems of TMJ. This finding is in line with those reported by Huang  and Huang, who stated that the possible complications after wisdom teeth extraction will increase the risk of primary TMJ problems. Moreover, Manoj stated that the surgical extraction of third molars must only be performed for dental impactions that are associated with clinical damaging conditions. Momin et al. stated that several risk factors are related directly with the precipitation of adverse effects after surgical removal of third molars. These factors include depth, site of impaction, use of surgical tools, and experience level of the operator, which is correlated directly with the development of negative outcomes following third molar extractions.
The sample size obtained and the age scope selected in this study may have an effect on the results of study. Therefore, it is important for future studies to take this into consideration by increasing the sample size and scope of selected ages.
| Conclusion|| |
The study concluded that impacted third molars are not considered to be an effective factor in the occurrence or development of TMJ clicking or sounds.
Ethical policy and institutional review board statement
This study was approved by the Ethics Committee of Dentistry College/Wasit University (Resolution nos. 641 in 1/6/2017) and is in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
My deep gratitude is to all the dental centers where the study was conducted, especially to radiology departments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]