The Latin word "erumpere," which means "to erupt" refers to the movement of a growing tooth as it goes from a non-functional position inside the jaw to its correct anatomical and functional location inside the dental arch.[ ] This process is vital to maintaining a dentition that is both healthy and properly aligned. However, a variety of dental irregularities may hinder this eruption, resulting to problems like impaction, the development of extra teeth, and changes in the size and shape of teeth. These abnormalities provide substantial issues for both the patients and the dental practitioners due to their possible consequences on appearance, function, and psychological well-being.[ ] Impaction occurs when a tooth fails to emerge in the correct position in the mouth and is one of the most common dental irregularities linked to tooth eruption. Multiple studies indicate that the prevalence of the issue is approximately 40% regarding at least one affected wisdom tooth worldwide.[ ] Other studies estimate that almost half of the worldwide population has some sort of anomaly related to their third molars, either being congenitally absent, fully impacted, or partially impacted.[ ]  Pain, particularly caries, inflammation, gum soreness, an unpleasant taste in the mouth, and difficulty moving the jaw can all result from impacted wisdom teeth.[ ] Various elements, such as bone structure, sex, age, and ethnic background, influence the occurrence of mandibular third molar impaction[ ]   Multiple local and systemic and genetic elements play a role in tooth impaction. Local factors comprise mechanical obstructions, including cysts, tumors, and extra teeth. Insufficient space in the dental arch, frequently due to issues like micrognathia (a diminutive jaw), early loss of primary teeth, or mismatches in tooth and arch dimensions, can lead to impaction. Moreover, specific health issues like malnutrition, anemia, rickets, and congenital defects, including cleft lip and palate, endocrine deficiencies (hypothyroidism and hypopituitarism), have been associated with a higher likelihood of impacted teeth.[ ] Genetic conditions like cleidocranial dysplasia, Down syndrome, Gardner syndrome, Gorlin–Sedano syndrome have all been linked to impacted teeth.[1, ] Impacted third molars can lead to various dental complications, including cavities, pericoronitis, bone loss, resorption of adjacent tooth roots, periodontal disease, and cyst formation and squamous cell carcinoma. A significant risk linked to impacted mandibular third molars is the possibility of damaging the inferior alveolar nerve during removal. Injury to this nerve may lead to changed sensations, such as numbness, tingling, or a burning feeling on the impacted side of the jaw. [ ] Interruption of the IAC cortex, root darkening, dark of bifid apices, canal narrowing is among the morphological predictors of diversion, deflected roots and root narrowing are among the morphological predictors of greater IAN injury after mandibular third molar surgery according to study. Even though IAN injuries are still a concern, 96–99% of cases heal in 4–8 weeks, with age and gender having no bearing on healing. Nonetheless, some injuries—which can range from mild hypoesthesia to total anesthesia—may last longer than six months and, in certain situations, develop into neuropathic pain Early detection is crucial for preventing complications and ensuring appropriate management.[ ] After third molars, the maxillary canine is the second most frequently impacted tooth, with an observed prevalence between 1% and 2.5%, mainly affecting females.[ ] The heightened risk of impaction is due to the prolonged and intricate eruption route of the canine, along with the longer duration needed for it to attain its ultimate occlusal position relative to other permanent teeth.[ ]  Becker et al. conducted research that identified a relationship between irregularities in the maxillary lateral incisors and the impaction of the maxillary canines. Multiple studies have indicated that there is a greater occurrence of canine impaction in people with abnormalities impacting the lateral incisors compared to those without such issues. When the lateral incisor is either malformed or absent, the necessary guidance for the correct eruption of the canine is hindered, raising the risk of canine impaction [, ] Canines have a significant role in ensuring the correct facial aesthetics and effective bite alignment. Research indicated that removing the deciduous canine prior to 11 years old could influence the eruption position of permanent canines in many instances, thus leading orthodontists to suggest various technical treatments to address the impacted canines, influenced by the level of impaction, which impacts early treatment success and the age of the patient. [ ] The position of the impacted maxillary canines is determined by clinical and radiographic assessments

Radiographic imaging is a very important aspect in the diagnosis of impacted teeth and associated pathologies. There are numerous imaging modalities available that help dentists decide on the position, orientation, and complications of impaction of teeth in the oral cavity. [ ] OPG imaging is widely used around the world to evaluate impacted mandibular third molars. OPG provides crucial diagnostic information by displaying the angulation, positioning, and connections of impacted teeth with adjacent structures. It is particularly advantageous for initial assessments, allowing clinicians to analyze crown-root anatomy, tooth alignment, and type of impaction[ ,  ].

OPG has become well-liked because of its simple use, relatively low radiation exposure compared to full periapical exams, and its ability to capture a broad range of structures with minimal overlap of intervening tissues. Additionally, OPG is the preferred imaging technique in cases where the patient faces trismus (limited mouth opening). Nonetheless, despite its advantages, OPG has certain limitations. A major drawback is the difficulty of correctly interpreting images of large anatomical regions like the temporomandibular joint (TMJ) and mandibular rami. This prompt questions the reliability of OPG in comprehensively assessing these structures. [ ]

Rational And Objectives: Owing to the complications brought about by impacted teeth, a retrospective radiographic study was conducted to evaluate the prevalence and pattern of third molar angulation, impaction, and eruption stages in patients treated at Hamdard Dental Hospital, Karachi. The purpose of this study was to detect the relationship between third molar impaction with the inferior alveolar nerve and the prevalence of 3rd molar and canine impaction in terms of gender differences.

Study Design

This was a cross-sectional retrospective study carried out in the Department of Oral & Maxillofacial Surgery at Hamdard University Dental Hospital, Karachi. This study was conducted for six months, from October 2022 to April 2023. The panoramic radiographs obtained were procured from the radiology section of the hospital for analysis. The sampling technique followed was non-probability convenience sampling. All OPG were taken by CRANEX D digital x-ray unit # 203371 version 3 with power frequency 50/60 Hz and magnetic field IEC 61000-4-11 as reported by the manufacture. SCANORA 5.2.6 SOFTWARE was used for imaging. Time of exposure was approximately 10-11 seconds with resolution of 1.34 DPI.

The study included participants who fulfilled the following criteria:

• Must be over 18 years old.
• Presence of an impacted permanent maxillary canine not likely to emerge.
• Patients with complete permanent teeth who have all their teeth present.
• Patients with impacted mandibular third molars on one or both sides.
• No previous orthodontic treatment.

Patients were not included if they fulfilled any of the subsequent criteria:

• Record of surgical or deliberate removal of the maxillary canine.
• Low-quality or unclear OPGs impacting visibility of the canine area.
• Third molars in the mandibular region exhibiting incomplete root development.
• Existence of congenital or developmental jaw irregularities.
• Existence of bony anomalies (e.g., cysts, odontogenic neoplasms, fibro-osseous abnormal growths).
• Presence of neighboring affected or absent second molars.
• A history of jaw injury, verified through clinical examination and imaging studies.

Assessment of Orthopantomograms (OPGs)

Initially, 1,294 OPG scans were reviewed. Following the application of the inclusion and exclusion criteria, a total of 1,192 OPGs were chosen for the final analysis. The assessment comprised:

• Quantity and classification of affected teeth.
• Demographic information of patients (gender and age).
• Position of affected teeth (upper jaw and/or lower jaw).

The affected mandibular and maxillary third molars were evaluated using:

Pell and Gregory Classification

• Assessment of impaction depth in relation to the position of the cementoenamel junction (CEJ) compared to the bone level:
• Level A: Equivalent height to the occlusal plane of the 2nd molar
• Level B: In the space between the occlusal surface and the cervical margin of the second molar.
• Level C: Underneath the cervical edge of the 2nd molar.
• Ramus Relationship – Assessed solely for mandibular third molars.
• Class 1: adequate distance between the ramus and the distal part of the 2nd molar.
• Class 2: The gap between the ramus and the distal of the second molar is reduced.
• Class3: completely integrated within the bone

Winters classification

• Measurement of Angulation
• Vertical impaction:
• Mesioangular impaction:
• Horizontal impaction:
• Distoangular impaction:

Other noted parameters included:

• Area of the affected canines (upper right or left side).
• Association of the inferior alveolar canal to the third molars.

Statistical Analysis

• The sample size was calculated with Open-Epi software version 3, using a 95% confidence level and a 5% error margin. The gathered data were examined with IBM SPSS Statistics for Windows, Version 27.0
• Frequency distributions and percentages for categorical variable were calculated using descriptive statistics.
• The Chi-square test was utilized to assess:
  • Relationship between arch (maxilla or mandible) and angle and depth of impaction.
  • Association between ramus relationship, angle of impaction, and depth in lower third molars.
• A p-value lower than 0.05 was deemed statistically significant.

The assessment of third molar impaction in the radiographs of 1193 patients indicated that the average age for males was 33.8 years and for females was 34.5 years, with the male to female ratio being 43% (n=512) and 57% (n=681) respectively. Vertical angulation was the most common orientation overall (46–48% for both males and females), followed by absent third molars and mesoangular in the mandibular posterior area.

Table1: Angulation and level of eruption of 3^rd molars (upper and lower jaws).

Approximately half of mandibular sites had sufficient ramal space (47–50%), while insufficient space occurred in 19–22%. Fully covered-in-ramus cases were uncommon. Association between 3rd molars and inferior alveolar canal involvement was statistically significant (p = 0.001), indicating relevant surgical risk as shown in table 2.

Table2: Frequency of Ramus with mandibular 3^rd molars and association with inferior alveolar nerve

Upper canines showed higher impaction counts than lower canines, with females demonstrating slightly higher prevalence than males. Most canine impactions presented in younger age groups (≤25 years) as shown in table 3

Table3: Frequency of canine impactions in females and males.

This retrospective analysis aimed to investigate the prevalence and distribution patterns of tooth impactions, focusing specifically on third molars and canines, within a population at the Hamdard dental hospital in Karachi. This research included data from 1193 participants, revealing a slight female majority (57%) and a mean age of 34.24 years. The findings provide crucial insights into the characteristics of impactions in this group

Third Molar Impactions

The examination of affected third molars concentrated on their angulation, eruption depth, and relationship with the mandibular ramus and the alveolar nerve.

Angulation and Distribution

This research offers statistical analysis of third molar angulation in the various quadrants and between genders. In males and females, the most frequently seen pattern of impaction across all quadrants was vertical. Females demonstrated a large number of vertical impactions in the lower jaw, whereas males exhibited high vertical impactions in upper jaw followed by mesoangular quadrants was vertical. Females demonstrated a large number of vertical impactions in the lower jaw, whereas males exhibited high vertical impactions in upper jaw followed by mesoangular. These results are in accordance with those of other studies conducted by Hira Butt  in Lahore, Kinza Ayub  in Islamabad and Alfadil L et al  and Idris AM et al 8 in Saudi Arabia, Sujon, M. K.   in Bangladeshi population found that mandibular wisdoms more frequently impacted as compared to maxillary wisdoms. Vertical impaction was more common followed by Mesioangular impactions in mandible and Distoangular in maxilla with no gender predilection. CN Naraynsingh et al,   reported that vertical type in the mandible and mesoangular in the maxilla were most frequently found, which is inconsistent with our results. These may reflect racial and genetic factors that influence jaw and tooth size, plus facial growth. The differences in the impaction pattern are further influenced by other variables, such as diet and masticatory function.

Level of eruption

Table 1 also shows the level of eruption of the third molars in relation to their neighbors, the second molars The majority of the third molars were in the category of "At occlusal level" and, therefore, partly erupted or in an otherwise better position, but still likely to be impacted followed by level C. These findings comparable with the study of CN Naraynsingh et al, 24 F. Liaqat   , whereas Kinza Ayub , in her study mentioned level B impactions predominant. These categorizations are essential in estimating the degree of difficulty in extracting these molars and in ascertaining likely pathologies. The age of eruption of third molars varies; some authors ,   report 20 to 23.5 years, and there was little difference across both men and women. The impact of sex on the third molar impaction is poorly defined, but some indicate that females are more affected than they are male has been reported due to leveling-off age. As wisdom teeth emerge, females cease growing laterally but males continue to grow their jaws outwardly which leaves more room for third molars.22

Association with Mandibular Ramus

This present study also assessed the prevalence of correlation between ramus and mandibular third molars. Significant numbers of mandibular third molars, in both male and female patients, showed "sufficient space" or class 1. It would in most cases denote a less complicated impaction setting. On the other hand, a significant number was found to have "Insufficient space" and only few (n=4%) were being fully covered in ramus or class III. It was in accordance to study conducted by Marghalani AA et al  . The absence of adequate space around the ramus presents one of the leading causative factors regarding impaction of the third molars and often leads to complex extractions surgically.

Association with Alveolar Nerve

A significant result from this study was the correlation of mandibular third molars to the alveolar nerve, with a p-value of .001. These are two critical results that stress the significant relationship between involved mandibular third molars and the inferior alveolar nerve. Their proximity is considered a known risk factor for nerve injury during surgical procedures of impacted wisdom teeth. In these cases, thorough preoperative evaluation by means of highly developed imaging techniques such as Cone Beam Computed Tomography is strongly recommended for the assessment of its spatial relationship to minimize potential complications.10

Canine Impactions

This research additionally investigated the occurrence of canine impaction, offering information of both genders across different age categories. Tables 3 illustrates the occurrence of canine impaction. In general, canine impactions seems to be less common than third molar impactions, aligning with worldwide prevalence statistics.18,   Our findings indicated that a higher number of impactions occurred in upper jaw than in lower jaw across all age groups. Similar findings are often reported in the literature, such as the fact that impacted maxillary canines are more common in females than in males and that maxillary canine impactions are more common than lower jaw canine impactions.  ,   This could be explained by the fact that women's maxilla is smaller than men's. The age distribution of canine impactions may be a reflection of the particular demographics or traits of the Karachi population, which can occur throughout a broad range, from 15 to 25 years old to 56 to 65 years old. This implies that diagnosis might happen at various stages of life. The long eruption path and delayed development of the maxillary canine tooth germ, greater bone density, and pressure from adjacent bony cavities, such as the nasal wall, orbital cavities, and maxillary sinus, can all contribute to unfavorable impaction of the maxillary canine. 

This retrospective study offers a useful overview of tooth impaction and was carried out in a secondary healthcare setting in Karachi. The findings related to the angulation of third molars, their eruption stages, and the important relationship with the alveolar nerve align with earlier studies, highlighting the importance of thorough preoperative assessment for surgical planning. Even though they generally present lower frequencies than third molars, the information regarding canine impactions also aids in understanding their distribution within the studied population and offers comparative perspectives on global frequency patterns. Further studies in a variety of demographics will advance our knowledge of the underlying causes and enhance impacted tooth care techniques.

1. Ahmed, H.A.; López-López, J.; Egido-Moreno, S.; Llabrés, X.R.; Hameed, M.; Estrugo-Devesa, A. Mandibular Third Molar Impaction and Bone Change Distal to the Second Molar: A Panoramic Radiographic Study. J. Clin. Med. 2024, 13, 906. https://doi.org/10.3390/jcm13030906
2. Helmi JM, Hagar AA, Al-Jawfi KA, Aldilami A & Al-Wesabi MA. Prevalence of impacted teeth among a sample of Yemeni population and their association with sex and age. J Oral Res 2019; 8(4):343-350. Doi:10.17126/joralres.2019.051
3. Shaikh AH, Muntaha S, Ahmed S, Zaidi SJA. Maxillary sinus involvement of maxillary third molars: An OPG study conducted at Dow International Dental College, Karachi. Professional Med J 2022; 29(4):475-481.https://doi.org/10.29309/TPMJ/2022.29.04.6432
4. Sujon MK, Alam MK, Rahman SA, Noor SN. Third molar impactions prevalence and pattern among adults using 5923 digital orthopantomogram. Bangladesh Journal of Medical Science. 2022;21(3):717 https://doi.org/10.3329/bjms.v21i3.59590.
5. Alrebdi A. Insight into Pattern of Third Molar Eruption-A Retrospective Study of Panoramic X rays Among Patients in Qassim Region, Saudi Arabia. Journal of International Dental and Medical Research. 2024 May 1;17(2):758-63.
6. Shareif MS, Paul S, Ghani NF, Fareez IM. Pattern of mandibular third molar impaction in Malaysia population and their association with gender, age and race. Journal of International Dental and Medical Research. 2020;13(1):194-200.
7. Sujatha, G., Sivapathasundharam, B., Sivakumar, G., Nalikumar, S., Ramasamy, M., Prasad, T.S., 2012. Idiopathic multiple impacted teeth: case report and discussion. J. Oral. Maxillofac. Pathol. 16, 125–127. DOI: 10.4103/0973-029X.92989
8. Idris AM, Al-Mashraqi AA, Abidi NH, Vani NV, Elamin EI, Khubrani YH, Alhazmi AS, Alamir AH, Fageeh HN, Meshni AA, Mashyakhy MH. Third molar impaction in the Jazan Region: Evaluation of the prevalence and clinical presentation. The Saudi Dental Journal. 2021 May 1;33(4):194-200. https://doi.org/10.1016/j.sdentj.2020.02.004

9. Lalremtluangi R and Khasbage SD. Comparative evaluation for the accuracy of mandibular third molar impaction status with respect to surrounding dentoalveolar structures using orthopantomogram as against cone beam computed tomography [version 1; peer review: 2 not approved]. F1000Research 2023, 12:1545 (https://doi.org/10.12688/f1000research.135179.1)
10. Bamdadianf T. Evaluation of impact teeth prevalence and related pathologic lesions in patients in Northern part of Iran (2014-2016). J Contemp Med Sci| Vol. 2018;4(1):30-2.
11. Sathyanarayana HP, Nucci L, d’Apuzzo F, Perillo L, Padmanabhan S, Grassia V. Prevalence, etiology, clinical features and management associated with impacted and transmigrated mandibular canines: a systematic review. BMC Oral Health. 2023 Dec 7;23(1):975.
12. Pajević T, Vasović D, Juloski J, Vučić L, Glišić B. Evaluation of the impacted maxillary canines position, determination of the possible indicators of the impaction difficulty, and the risk factors for adjacent teeth root resorption. Vojnosanitetski pregled. 2023 Sep 29;80(09). https://doi.org/10.2298/VSP220329010P
13. Kumar S, Hassan N, Kumar S, Anjan R, Kumar K, Bhowmick D. Radiographic Assessment of Maxillary Canine Impaction. Annals of the Romanian Society for Cell Biology. 2021;25(2):750-
14. Becker A. Buccally Impacted Maxillary Canines. Orthodontic Treatment of Impacted Teeth. 2022 Jan 6:215.
15. Khaleel, Ameera K.; Ali, Muna S.; Ali, Mustafa F.; Abbas, Moamel M.; Khudhur, Zahraa K.; Awad, Zahraa W.. Radiographic Assessment of the Prevalence and Pattern of Impacted Canines: A Cross-sectional Retrospective Radiographic Study. Medical Journal of Babylon 22(Suppl 1):p S18-S23, June 2025. | DOI: 10.4103/MJBL.MJBL_355_24
16. Chauhan V, Wilkins RC. A comprehensive review of the literature on the biological effects from dental X-ray exposures. Int J Radiat Biol. 2019;95:107–19. doi: 10.1080/09553002.2019.1547436.
17. Matzen LH, Villefrance JS, Norholt SE, Bak J, Wenzel A. Cone beam CT and treatment decision of mandibular third molars: removal vs. coronectomy: a 3-year audit. Dentomaxillofac Radiol. 2020;49:20190250. doi: 10.1259/dmfr.20190250.
18. ASSIRI H, Estrugo-Devesa A, Egido-Moreno S, Rosello-LLabres X, Hameed MS, Alqarni A, Lopez JL. Prevalence of mandibular third molar impaction, associated pathologies, and correlation with Temporomandibular joint morphology in Spanish Population: A panoramic radiography study. https://doi.org/10.21203/rs.3.rs-4887008/v1
19. Srivastava, Anupriya; Raghav, Pradeep; Pradhan, Sanchit1. Effectiveness of orthopantomograph in vertical mandibular measurements: A systematic review. Journal of Oral and Maxillofacial Radiology 9(2):p 45-51, May–Aug 2021. | DOI: 10.4103/jomr.jomr_9_21
20. ButtH, TahirF, IqbalA, RaufN, KhanNR, PirachaMH.Patterns of impacted third molars and categorization of their associated oral pathologies: A radiographic study.Pak J Pathol. 2021;32(3): 101-106.
21. Ayub, K., Fazal, M., Sattar, M., Khan, L., Malik, A., & Afzaal, A. (2024). Pattern of Mandibular Third Molar Impaction in Patients from Twin Cities of Pakistan. Journal of Women Medical and Dental College, 2(2). https://doi.org/10.56600/jwmdc.v2i2.74.
22. Alfadil L, Almajed E. Prevalence of impacted third molars and the reason for extraction in Saudi Arabia. The Saudi dental journal. 2020 Jul 1;32(5):262-8.
23. Sujon, M. K. ., Alam, M. K. ., Rahman, S. A. ., & Mohd Noor, S. N. F. . (2022). Third Molar Impactions Prevalence and Pattern Among Adults Using 5923 Digital Orthopantomogram. Bangladesh Journal of Medical Science, 21(3), 717–729. https://doi.org/10.3329/bjms.v21i3.59590
24. Naraynsingh C, Henry K ., Hunte R, Ramlogan N, Bissoon A. Prevalence and pattern of tooth impaction: a radiographic study in a trinidadian population. NJCP [Internet]. 2025 Mar. 29 [cited 2025 Nov. 12];27(7):837-43.
25. Liaqat F, Gakhar A, Siddiqui ZW, Jabbar M, Fatima S, Butt H. Inter-Rater Reliability among Dentists for Assessment of Depth of Impacted Third Molars on Orthopantomograms. Pakistan Journal of Medical & Health Sciences. 2023 Feb 26;17(01):388-. DOI: https://doi.org/10.53350/pjmhs2023171388
26. Ayub, K., Fazal, M., Sattar, M., Khan, L., Malik, A., & Afzaal, A. (2024). Pattern of Mandibular Third Molar Impaction in Patients from Twin Cities of Pakistan. Journal of Women Medical and Dental College, 2(2). https://doi.org/10.56600/jwmdc.v2i2.74.
27. Shaweesh AI. Timing of clinical eruption of third molars in a Jordanian population. Archives of Oral Biology. 2016 Dec 1;72:157-63.
28. Sudalaimuthu R, Seethalakshmi M, Sivakkumar S, Priya S. Assessment of age by third molar eruption among females in South Tamilnadu. Journal of Evolution of Medical and Dental Sciences. 2015 Sep 24;4(77):13377-81.
29. Marghalani AA, Alsaggaf AU, Hazzazi A, Dahlawi A, Badaoud MB, Alhazmi F, Alnefaie I, Bukhari OM, Demyati AK. Radiographic characteristics of impacted teeth: A retrospective study of 2199 radiograph. Plos one. 2025 Feb 13;20(2):e0316749.
30. Pinto, A. C., Francisco, H., Marques, D., Martins, J. N. R., & Caramês, J. (2024). Worldwide Prevalence and Demographic Predictors of Impacted Third Molars—Systematic Review with Meta-Analysis. Journal of Clinical Medicine, 13(24), 7533. https://doi.org/10.3390/jcm13247533
31. Hagar AA, Helmi JM, Al-Jawfi KA, Al-dilami A, Al Wesabi MA. Prevalence of impacted teeth among a sample of yemeni population and their association with sex and age. J. oral res.(Impresa). 2019:343-50.
32. Al-Mayali AM, Nahidh M, Alnajar HA, Fahad AH. Impaction prevalence of permanent teeth pattern from orthodontic view. EurAsian Journal of BioSciences. 2020;14(2):2823-8.
33. Hajmohammadi E, Khiavi HM, Baghi AN, Khalili V, Zohoori S. The assesment of pattern of maxillary canine impaction in the Ardabil city. Journal of Craniomaxillofacial Research. 2020 Dec 26:138-44.