Int. J. Oral Maxillofac. Surg.

2013; 42: 843–851

http://dx.doi.org/10.1016/j.ijom.2013.01.023, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Risk factors associated with T. Hasegawa1, S. Ri2, T. Shigeta1,

M. Akashi1, Y. Imai1, Y. Kakei1,
Y. Shibuya1, T. Komori1

inferior alveolar nerve injury

1
Department of Oral and Maxillofacial
Surgery, Kobe University Graduate School of
Medicine, Kobe, Japan; 2Department of Oral
and Maxillofacial Surgery, Kobe Steel

after extraction of the Hospital, Kakogawa, Japan

mandibular third molar—a

comparative study of
preoperative images by
panoramic radiography and
computed tomography
T. Hasegawa, S. Ri, T. Shigeta, M. Akashi, Y. Imai, Y. Kakei, Y. Shibuya, T.
Komori: Risk factors associated with inferior alveolar nerve injury after extraction of
the mandibular third molar—a comparative study of preoperative images by
panoramic radiography and computed tomography. Int. J. Oral Maxillofac. Surg.
2013; 42: 843–851. # 2013 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. In this study we investigated the relationships among the risk factors for
inferior alveolar nerve injury (IANI), and the difference between preoperative
imaging findings on panoramic radiographs and computed tomography (CT), by
univariate and multivariate analyses. We determined the following to be significant
variables by multivariate analysis: panoramic radiographic signs, such as the loss of
the white line of the inferior alveolar canal or the diversion of the canal; excessive
haemorrhage during extraction; and a close relationship of the roots to the IAN (type 1
cases) on CT examination. CT findings of type 1 were associated with a significantly
higher risk (odds ratio 43.77) of IANI. In addition, many panoramic findings were not
consistent with CT findings (275 of 440 teeth; 62.5%). These results suggest that CT
Key words: mandibular third molar; hypoesthe-
findings may be able to predict the development of IANI more accurately than
sia; inferior alveolar nerve injury; computed
panoramic findings. Panoramic radiography alone did not provide sufficiently reliable tomography; multivariate analysis.
images required for predicting IANI. Therefore, when the panoramic image is
suggestive of a close relationship between the impacted tooth and the IAN, CT should Accepted for publication 21 January 2013
be recommended as a means of conducting further investigations. Available online 15 March 2013

0901-5027/070843 + 09 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
844 Hasegawa et al.
The removal of the mandibular third molars
to prevent future problems is widely
acknowledged to be useful and is one of
the most commonly performed surgical
procedures in oral surgery. The surgical
removal of these molars may damage the
nerve and cause hypoesthesia of the lower
lip as an unpleasant postoperative compli-
cation.1–22 Many investigators have
reported that inferior alveolar nerve injury
(IANI) is associated with mandibular third
molar removal.1–22 However, there have
been few quantitative analyses of the fac-
tors contributing to IANI. In addition, other
than our recent study,23 only a few studies
to date have evaluated the multivariate
relationships among the various risk factors
and IANI.11,16,17 In our recent study, we
reported some radiographic signs (the loss
of the white line of the inferior alveolar
canal, the diversion of the canal, and a close
relationship of the roots to the IAN on
panoramic radiographic findings and not
on CT findings) to be significantly asso-
ciated with IANI following third molar
extraction.23
Panoramic radiographs are the imaging
modality most commonly used by oral and
maxillofacial surgeons to view impacted
third molars and to estimate the risk of
IANI.13 In particular, Rood and Shehab
reported that three of seven classic radio-
graphic signs indicate a higher risk of IANI,
implicating close proximity of the inferior
alveolar nerve (IAN) to the lower third
molar.7 However, some investigators have
reported that panoramic radiography does
not provide sufficiently reliable images to
predict nerve lesions.13,24,25 In addition,
some reports have indicated that it is only
possible to determine the true relationship
of the tooth root with the IAN with com-
puted tomography (CT).13,24–26 In fact,
axial, coronal, and sagittal CT images all
provide surgeons with useful information,
and such images are also beneficial for the
preoperative planning of the surgical pro-
cedure because of the high-resolution qual-
ity of medical CT.25 In this study, we
investigated the multivariate relationships
among the various risk factors of IANI, and
the differences between preoperative ima-
ging findings on panoramic radiographs
and medical CT images.
Patients and methods
This was a non-randomized, retrospective
(historic) cohort study of patients. Thus,
this study was granted exemption from
institutional review board approval.
Between April 2006 and March 2010,
2528 surgical removals of mandibular
third molars were performed by dentists
at the Department of Oral and Maxillofa-
cial Surgery.
A total of 376 (high risk of IANI; types
1, 2, and 3 as described in ‘Study design’
section) of the 2528 teeth were found to be
in close association with the mandibular
canal on panoramic radiograph, or were
expected to be very difficult to extract (for
example, in cases with hypertrophic roots
and/or dilacerated teeth). Sixty-four (low
risk of IANI; types 4 and 5) of the 2528
teeth were opposite to the other teeth that
were in close proximity to the IAN. A total
of 440 teeth from 295 patients (122 men
and 173 women) were included in this
study. The patients had a mean age of
36.2  12.2 years (range 16–71 years).
Thus the data (total 440 teeth) for this
study pertain to the impacted lower third
molars considered to have a high level of
risk of IANI during surgery. Before sur-
gery, each patient was informed of the
necessity to perform a CT examination
and the possible complications, including
the potential risk of IANI during the pro-
cedure.
Surgical methods
Every intervention was carried out under
local or general anaesthesia. The extrac-
tion of 147 teeth (33.4%) in 86 patients
was carried out under general anaesthesia;
for 293 teeth (66.6%) in 209 patients, the
procedure was carried out under local
anaesthesia. Sedation was not carried
out. Envelope (sulcular) mucoperiosteal
flaps were raised for superficial impac-
tions, and triangular flaps were raised
for deep impactions, followed by vestib-
ular bone removal. If necessary, bone
removal and crown and root sectioning
were performed with tungsten fissure burs
(Dentsply-Maillefer, Ballaigues, Switzer-
land). Sockets were irrigated with 20 ml
sterile saline solution at room temperature,
and exposure of the IAN was checked
during and after precisely focused careful
suction. A 3–0 silk suture was used to
close the wound. An antibiotic and an
anti-inflammatory drug were prescribed
(usually oral cefcapene pivoxil hydro-
chloride hydrate 900 mg 3 times daily
for 3 days and oral acetaminophen
1200 mg 3 times daily for 3 days). After
7 days, a surgeon removed the suture and
explored the wound for closure and
recorded any complications such as ecchy-
mosis, trismus, swelling, postoperative
bleeding, dry socket, infection, and IANI.
Study design
Patients who underwent conventional
panoramic radiography (Orthoceph
OC100CT; Yoshida, Tokyo, Japan) were
included in the study. The radiation dose
was 20–30 mSv. The medical CT images
were taken using a High-Speed Advantage
CT Scanner (GE Medical Systems-Japan,
Tokyo, Japan). The exposure factors were
set at 120 kV and 200 mA, and the dura-
tion of scanning was 6 s. The slice thick-
ness of contiguous sections was
0.625 mm. Axial planes were set parallel
to the occlusal plane, and continuous
0.625-mm slices were taken. Coronal
and sagittal images were reconstructed
from the raw data. The software program
used was Advantage Workstation1 (GE
Medical Systems-Japan). The radiation
dose was 2.0–3.0 mSv.
The primary predictive variable was the
presence or absence of one or more
panoramic radiographic or CT findings.
The panoramic radiographic and CT find-
ings were analyzed independently by the
first and second authors. These two
authors were blinded independently to
the postoperative IANI status. The CT
images were presented to the two obser-
vers in a randomized order to prevent
referral to the panoramic findings. When-
ever a disagreement occurred between the
two observers’ assessments, a consensus
was reached by discussion. At first, the
panoramic findings were evaluated for the
presence or absence of the following three
classic radiographic signs, all of which
have been reported as suggestive of a close
proximity of the IAN to the lower third
molar7: (1) darkening of the root where it
crosses the inferior alveolar canal (as
described below, this group was classified
into types 1 and 2 on panoramic radio-
graphic findings and not on CT findings);
(2) interruption or obliteration of either of
the radiopaque white (cortical) lines of the
inferior alveolar canal; and (3) diversion
or bending of the inferior alveolar canal in
the region of the root apices. In addition,
the relationship of the roots to the IAN in
the panoramic radiographic findings was
diagnosed radiographically in accordance
with the method reported by Tanaka et al.
(Fig. 1).27 In type 1 cases, the canal is
superimposed over more than half of the
root structure. In type 2 cases, the canal is
superimposed over less than half of the
root structure. In type 3 cases, the root
structure impinges on the superior border
of the canal. In type 4 cases, the distance
between the root tip and the superior
border of the canal is less than 2 mm,
and in type 5 cases, the distance between
the root tip and the superior border of the
canal is more than 2 mm.
The relationship of the roots to the IAN
was diagnosed by CT with the same

Fig. 1. The classification of the relationship of the roots to the IAN.
method that was used for the panoramic
radiographic findings (Fig. 2). In types 1
and 2, the disappearance of cortication of
the canal is observed. In type 1, displace-
ment of the nerve contents to curve around
the root is observed. In the CT images, the
relationship was also classified in terms of
the buccolingual position into one of the
four following categories: buccal, inferior,
lingual, or inter-radicular (Fig. 3).
Fig. 2. The classification of the relationship of the roots to the IAN on CT images.
Inferior alveolar nerve injury after extraction
The following were analyzed and com-
pared by the method reported in our pre-
vious study23: preoperative radiographic
findings, such as the type of impaction
(according to Pell and Gregory28), angula-
tion (Winter classification29), three radio-
graphic signs associated with IANI (listed
above), and the classification (types 1–5)
according to the method reported by
Tanaka et al. (Fig. 1)27; procedure-related
845
complications during surgery, such as the
observation of the canal, excessive hae-
morrhage, and bone removal; and demo-
graphic factors, including patient age and
gender. All factors are listed in Table 1.
When the data were introduced into a
multiple logistic regression model, the
patients were divided according to the
relationship of the roots to the IAN (type
1 vs. types 2–5; buccal and inferior vs.
lingual and inter-radicular). Patients were
similarly divided into two groups based on
age (under 25 years and over 25 years),
and into three groups based on the sur-
geon’s seniority (experience of 1–4 years,
5–9 years, and >10 years). In our previous
study, we demonstrated the multivariate
relationships among various risk factors
on panoramic radiographic findings with-
out CT findings and IANI. In this study,
we investigated the multivariate relation-
ships among various risk factors (includ-
ing CT findings) and IANI.
Only patients with preoperative sensory
deficits were excluded. All patients were
specifically questioned about their chin and
lip sensitivity. IAN sensory impairment
was detected by pin-prick and light touch
test. In cases where there was diminution of
sensation, a neurological examination
assessed the degree of the deficit. The
lesion was classified as either dysesthesia
(painful sensation triggered by non-nox-
ious stimuli), hypoesthesia (diminished
sensation), or anaesthesia (absence of sen-
sation), and was monitored after 10 and 20
days and 1, 3, and 6 months, until total
recovery.
Statistical analysis
Data collection and statistical analyses were
carried out with SPSS 15.0 (SPSS, Chicago,
IL, USA) and StatView J-4.5 software
(Abacus Concepts, Berkeley, CA, USA).
The association of each variable with the
presence of IANI was tested by Mann–
Whitney U non-parametric test for age
and Fisher’s exact test for categorical vari-
ables. A P-value of <0.05 was considered
statistically significant. All of the variables
associated with IANI were introduced into a
multiple logistic regression model. Forward
stepwise algorithms were used, with the
rejection of those variables that did not fit
the model significantly. Multivariate odds
ratios (ORs) and 95% confidence intervals
(CIs) were also calculated for the significant
signs. A P-value of <0.05 was considered
statistically significant.
Results
The incidence of IANI at 1 month after
surgery was 28 of 440 teeth (6.4%) in 26
846 Hasegawa et al.
Fig. 3. The location of the IAN relative to the third molar roots on CT images.
patients. All of the patients with IANI had
hypoesthesia. None of the patients had
dysesthesia or anaesthesia. All of the
patients with IANI received corticoster-
oids (hydrocortisone, 100 mg) 1 day after
undergoing surgery. However, we did not
perform a surgical intervention to the IAN
canal in any of the cases because the
patients with IANI did not wish to undergo
such treatment.
Demographic factors
The patients with IANI had a mean age of
40.5  12.4 years (range 22–69 years).
The patients without IANI had a mean
age of 35.4  11.9 years (range 16–71
years). The patients with IANI were sig-
nificantly older than those without IANI
by univariate analysis (P < 0.05) (Table
1). There were no significant differences
between the sexes with regards to the
presence or absence of IANI (Table 1).
Procedure-related factors
IANI developed in three of 71 teeth (4.2%)
in patients treated by the surgeons with 1–
4 years of experience, in 14 of 175 teeth
(8.0%) in the group treated by surgeons
with 5–9 years of experience, and 11 of
194 teeth (5.7%) in the group of patients
treated by surgeons with >10 years of
experience. The incidence of IANI after
extraction by surgeons with 5–9 years of
experience was the highest in the three
groups. However, there was no significant
difference in the incidence based on sur-
geon seniority (Table 1).
The IAN was exposed in 17 of all 440
teeth (3.9%). Postoperative IANI devel-
oped in five of these 17 cases of exposure
(29.4%). The ratio of IANI in the extrac-
tion groups with nerve exposure was sig-
nificantly higher (P < 0.05) than in
patients without exposure (Table 1).
Excessive haemorrhage occurred dur-
ing the extraction of six of the 440 teeth
(1.4%). Postoperative IANI developed in
five (83.3%) of these six cases of exces-
sive haemorrhage. The development of
IANI in the extraction group with exces-
sive haemorrhage was significantly higher
(P < 0.05) than in the cases without
excessive haemorrhage (Table 1).
Radiographic factors: panoramic
radiographs
The most common Winter classification
was mesioangular (158 teeth, 35.9%),
while the least common Winter classifica-
tion was distoangular (22 teeth, 5.0%).
The most frequent Pell and Gregory clas-
sification in the 440 teeth was IIB. In the
multivariate analysis, no significant differ-
ences were indicated.
Panoramic radiographic signs indicat-
ing the loss of the white line of the inferior
alveolar canal were present in 22 of the
440 teeth (5.0%). The ratio of IANI in the
extraction group with the loss of the white
line of the inferior alveolar canal was
significantly higher (P < 0.05) than in
cases without the loss (Table 1). Similarly,
panoramic radiographic evidence of the
diversion of the canal was demonstrated in
28 of the 440 teeth (6.4%). The ratio of
IANI in the extraction group with the
diversion of the canal was significantly
higher (P < 0.05) than in the patients
without diversion (Table 1).
The most common panoramic radio-
graphic sign regarding the relationship
of the roots to the IAN was type 1, which
was diagnosed in 173 of the 440 teeth
(39.3%). The least common panoramic
radiographic sign was type 5, which was
diagnosed in 26 of the 440 teeth (5.9%).
The ratio of IANI in the extraction group
with type 1 classification was significantly
higher (P < 0.05) than in the patients with
other types of classification (Table 1).
However, there were no significant differ-
ences indicated by the multivariate analy-
sis.
Radiographic factors: CT
The most common CT radiographic sign
regarding the relationship of the roots to
the IAN was type 3, which was diagnosed
in 127 of the 440 teeth (28.9%). The least
common CT radiographic sign was type 2,
which was diagnosed in 67 of the 440 teeth
(15.2%). The ratio of the difference
between the types of panoramic and CT
radiographic signs was 275/440 (62.5%)
(Table 2). Of the 173 teeth with type 1
panoramic findings, 24 (13.9%) were
associated with IANI. Of the 86 teeth with
type 1 CT findings, 26 (30.2%) were asso-
ciated with IANI (Table 3).
Of the 440 teeth, 146 (33.2%) IANs
were in the buccal position, 195 (44.3%)
were in the inferior position, 95 (21.6%)
were lingual, and four (0.9%) were in the
inter-radicular position (Table 1). The
ratio of IANI in the extraction group with
a lingual position between the roots was
significantly higher (P < 0.05) than that in
the group with other positions (Table 1).
However, there were no significant differ-
ences indicated by a multivariate analysis.
Applying the logistic regression model
and forward stepwise algorithms, we deter-
mined the following to be significant vari-
ables: panoramic radiographic signs of the
loss of the white line of the inferior alveolar
canal or the diversion of the canal, exces-
sive haemorrhage during extraction, and
the close relationship of the roots to the
IAN on CT examination (Table 4). Patient
gender, surgeon seniority, and the Winter
 Inferior alveolar nerve injury after extraction 847

Table 1. Characteristics and incidence rates of radiographic signs and their relationships to IANI after third molar extraction.
Variables IANI present, n (%) IANI absent, n (%) P-value
Demographic factors
Sample size 28 (6.4) 412 (93.6)
Gender
Male 14 (53.8) 108 (40.1)
Female 12 (46.2) 161 (59.9) NS
Age, years
Range 22–69 16–71
Mean  SD 40.5  12.4 35.4  11.9 <0.05a
Panoramic findings
Right vs. left
Right 14 (50.0) 199 (48.3)
Left 14 (50.0) 213 (51.7) NS
Position
Winter’s classification
Vertical 4 (14.3) 73 (17.7)
Horizontal 9 (32.1) 132 (32.0)
Mesioangular 13 (46.4) 145 (35.2)
Distoangular 1 (3.6) 21 (5.1)
Transverse 1 (3.6) 41 (10.0) NS
Pell and Gregory
I 1 (3.6) 104 (25.2)
II 16 (57.1) 226 (54.9)
III 11 (39.3) 82 (19.9) <0.05b
A 3 (10.7) 120 (29.1)
B 19 (67.9) 220 (53.4)
C 6 (21.4) 72 (17.5) NS
Extent of root tip–inferior alveolar canal overlap (the method of Tanaka et al.) (Fig. 1)
Type 1 24 (85.7) 149 (36.2)
Type 2 3 (10.7) 90 (21.8)
Type 3 1 (3.6) 109 (26.5)
Type 4 0 (0) 38 (9.2)
Type 5 0 (0) 26 (6.3) <0.05b
Signs indicating close spatial relationship
Loss of the white line
Yes 9 (32.1) 13 (3.2)
No 19 (67.9) 399 (96.8) <0.05b
Diversion of the canal
Yes 11 (39.3) 17 (4.1)
No 17 (60.7) 395 (95.9) <0.05b
CT findings
Extent of root tip–inferior alveolar canal overlap (the method of Tanaka et al.) (Fig. 3)
Type 1 26 (92.9) 60 (14.6)
Type 2 2 (7.1) 65 (15.8)
Type 3 0 (0) 127 (30.8)
Type 4 0 (0) 81 (19.7)
Type 5 0 (0) 79 (19.2) <0.05b
Signs indicating close spatial relationship
Buccal position 3 (10.7) 143 (34.7)
Inferior position 0 (0) 195 (47.3)
Lingual position 21 (75.0) 74 (18.0)
Inter-radicular position 4 (14.3) 0 (0) <0.05b
Procedure factors
Canal observed
Yes 5 (17.9) 12 (2.9)
No 23 (82.1) 400 (97.1) <0.05b
Excessive haemorrhage
Yes 5 (17.9) 1 (0.2)
No 23 (82.1) 411 (99.8) <0.05b
Bone removal
Yes 28 (100.0) 325 (78.9)
No 0 (0) 87 (21.1) <0.05b
Surgeon experience
1–4 years 3 (10.7) 68 (16.5)
5–9 years 14 (50.0) 161 (39.1)
>10 years 11 (39.3) 183 (44.4) NS
IANI, inferior alveolar nerve injury; NS, not significant; SD, standard deviation.
a
Mann–Whitney U-test.
b
Fisher’s exact test.
848 Hasegawa et al.

Table 2. Results of the comparison of the panoramic and CT findings regarding the extent of root tip–inferior alveolar canal overlap.
CT findings
Panoramic findings Ratio of discordance
Type 1 Type 2 Type 3 Type 4 Type 5
Type 1 69 35 34 22 13 60.1% (104/173)
Type 2 14 18 36 16 9 80.6% (75/93)
Type 3 3 13 46 28 20 58.2% (64/110)
Type 4 0 1 10 11 16 71.1% (27/38)
Type 5 0 0 1 4 21 19.2% (5/26)
Average 62.5% (275/440)
CT, computed tomography. The bold type demonstrated the number of the difference between the types of panoramic and CT radiographic signs.

Table 3. Relationship between IANI and the extent of root tip–inferior alveolar canal overlap.a
CT findings
Panoramic findings
Type 1 Type 2 Type 3 Type 4 Type 5
Type 1 24/69 (34.8%) 0/35 (0%) 0/34 (0%) 0/22 (0%) 0/13 (0%) 24/173 (13.9%)
Type 2 2/14 (14.3%) 1/18 (5.6%) 0/36 (0%) 0/16 (0%) 0/9 (0%) 3/93 (3.2%)
Type 3 0/3 (0%) 1/13 (7.7%) 0/46 (0%) 0/28 (0%) 0/20 (0%) 1/110 (0.9%)
Type 4 0/0 (0%) 0/1 (0%) 0/10 (0%) 0/11 (0%) 0/16 (0%) 0/38 (0%)
Type 5 0/0 (0%) 0/0 (0%) 0/1 (0%) 0/4 (0%) 0/21 (0%) 0/26 (0%)
Total 26/86 (30.2%) 2/67 (3.0%) 0/127 (0%) 0/81 (0%) 0/79 (0%) 28/440 (6.4%)
CT, computed tomography; IANI, inferior alveolar nerve injury.
a
Complication present/absent (%).

classification were excluded from this
model because these factors were not sig-
nificant in the univariate analysis. The mul-
tivariate adjusted ORs and 95% CIs of the
included factors were calculated. The dis-
criminant hit ratio (96.1%) was considered
to be excellent in this study.
Discussion
Indications for the removal of third molars
are pathologic findings and prevention.
Whereas the removal of the third molars
with pathologic findings is indisputably
necessary, the benefit of preventive
removal is controversial. In our depart-
ment, the third molars are removed if their
physiological eruption is not expected, in
accordance with the general practice in
Japan. In other countries such as the UK
and the USA, preventive removal is partly
rejected because of the immense health
care resources that are required. The dis-
cussion deals with the question of whether
or not preventive removal is more expen-
sive than therapy in the case of sympto-
matic pathologic findings. However, in
general, no consensus guidelines presently
exist.
IANI is a characteristic complication
following the removal of an impacted
tooth.1–22 This complication often leaves
the patient dissatisfied with the surgery.
Predicting IANI before surgical interven-
tion is thus a common desire for the
surgeon and the patient. Therefore, a pre-
operative assessment should be carried out
radiologically to identify the proximity of
the impacted tooth to the inferior alveolar
canal. Many investigators have reported
that IANI is associated with mandibular
third molar removal.1–5,7–15,18–20 How-
ever, few studies to date have evaluated
the multivariate relationships among the
various risk factors and IANI.11,16,17 We
recently demonstrated the multivariate
relationships among risk factors and
IANI.23 We reported that some radio-
graphic signs were significantly associated
with IANI following third molar extrac-
tion.23 However, other reports have indi-
cated that it is only possible to determine
the true relationship of the tooth root with
the IAN using CT.13,24–26 Therefore, in
this study, we investigated the multivari-
ate relationships among the various risk
factors and IANI and the difference
between preoperative imaging findings
on panoramic radiographs and multi-pla-
nar reconstruction CT scans.
Other studies have reported the inci-
dence of postoperative IANI to be in the
range of 0.4–8.4%.1–15 In the present
study, the incidence of IANI was 6.4%
(28/440 teeth). The ratio of permanent
hypoesthesia (over 6 months) was 1.8%
(8/440 teeth). The incidence in our current
study was higher than that in many other
studies, because these impacted lower
third molars were considered to have a
high risk of damage to the canal during
surgery and were thought to need an
examination by CT scanning. In our pre-
vious study, the ratio of temporary (at 1
month) hypoesthesia was 1.3% (34/2528

Table 4. Results of the multivariate logistic regression analysis of the risk factors of IANI.
95% confidence interval
Variable P-value Odds ratio
Lower Upper
Excessive haemorrhage 0.006 99.04 3.83 2560.32
The loss of the white line <0.001 13.56 3.34 55.09
The diversion of the canal 0.001 10.41 2.75 39.46
The close relationship of the roots to <0.000 43.77 9.27 206.76
the IAN (type 1 of CT)
CT, computed tomography; IAN, inferior alveolar nerve; IANI, inferior alveolar nerve injury.

Table 5. Rates of the different locations of the IAN of the third molars reported in other studies.
Author Cases
Ohman et al., 200631 90
Kaeppler, 200032 345
Tantanapornkul et al., 200733 142
Mahasantipiya et al., 200534 202
Ito et al., 199435 47
Tanaka et al., 200027 209
Hashizume et al., 200436 68
Maegawa et al., 200325 47
Present study 440
IAN, inferior alveolar nerve.
teeth), and that of permanent hypoesthesia
(over 6 months) was 0.6% (15/2528
teeth).23
In this study, no significant correlations
were identified based on a multivariate
analysis between age and sex of the
patient, or surgeon seniority, and IANI.
These results are similar to those of our
previous study.23 It appears that IANI has
a stronger relationship with procedure-
related and radiographic factors than
demographic factors.
The incidence of excessive haemor-
rhage during extraction was noted to be
associated with an increase in IANI, both
in our present report and in other
reports.1,8,9,11,15,18 In this study, the pre-
sence of excessive haemorrhage during
extraction was associated with a higher
risk of IANI, similar to our previous study.
In addition, the development of excessive
haemorrhage (OR 99.04) was associated
with a higher risk of IANI as indicated by a
multivariate analysis. However, the iden-
tification of the IAN canal can be difficult
due to inadequate access to visualize the
canal or to haemorrhaging that obscures
the canal. Therefore, it is unclear whether
haemorrhaging is merely a consequence of
a disruption of the IAN canal, or whether it
originates from some other source and
actually represents the cause of IANI,
resulting from compression. For example,
IANI may be related to indirect trauma
from surgical oedema or to the formation
of a haematoma.
In the panoramic findings, the loss of
the white line of the inferior alveolar canal
(OR 13.56) and the diversion of the canal
(OR 10.41) were significant risk factors
for IANI, similar to other
reports.1,6,7,11,16,18 Umar et al. also
reported that loss of the radiopaque white
lines of the inferior alveolar canal and
diversion of the canal were both asso-
ciated with loss of cortication of the canal
on a cone beam CT scan.26 The authors
also reported that the two signs were
Inferior alveolar nerve injury after extraction
Locations (%)
Buccal Inferior
31.1 25.6
53.6 6.0
25.4 45.1
15.3 42.6
55.3 36.2
39.2 47.4
23.5 33.8
51.1 19.1
33.2 44.3
crucial predictive signs for an increased
risk of IANI during third molar extraction.
These results are similar to those observed
in our study.
In almost all Japanese subjects, the
buccolingual course of the IAN passes
through one-third of the lingual side of
the area between the mandibular foramen
and the second molar. The course reaches
a point about 6 mm away from the apex of
the second molar and makes a turn to the
buccal side of the mandibular bone.30
Some investigators have reported the rates
of the different locations of the IAN of the
third molars (Table 5).25,27,31–36 Several of
these studies on the course of the man-
dibular canal reported a predominantly
buccal course, although results vary
(Table 5). Our results showed that it
was buccal in 33.2%, inferior in 44.3%,
lingual in 21.6%, and inter-radicular in
0.9% of cases; in this study, the inferior
course was the most common, similar to
the reports of Maegawa et al.,25 Tantana-
pornkul et al.,33 and Mahasantipiya et al.34
In fact, in type 5 cases, as determined by
the panoramic findings (where the dis-
tance between the root tip and the superior
border of the canal was more than 2 mm),
the findings were similar to the CT find-
ings. However, in type 1–4 cases, many
panoramic findings were not consistent
with the CT findings (275 teeth; 62.5%).
Therefore, panoramic radiography alone
did not provide images reliable enough for
predicting nerve lesions. These results
suggest that panoramic radiographic
methods are marred by projection errors.
In the panoramic radiographic methods,
the vertical magnification factor can be
regarded as reliable for practical clinical
purposes if the object is properly posi-
tioned when performing the radiographs.
However, minor differences in magnifica-
tion factors may also exist when the object
is at different distances from the film
plane. In this study, of the 173 teeth with
type 1 panoramic findings, 24 (13.9%)
849
Lingual Inter-radicular
33.3 10.0
13.0 26.8
26.1 3.5
30.2 12.4
2.1 6.4
10.0 3.3
39.7 2.9
25.5 4.3
21.6 0.9
were associated with IANI. Of the 86 teeth
with type 1 CT findings, 26 (30.2%) teeth
were associated with IANI. In fact, a close
relationship of the roots with the IAN
(type 1) by CT examination, but not by
panoramic examination, was identified as
a significant variable according to the
multivariate analysis. The close relation-
ship of the roots to the IAN, such as type 1
cases by CT findings, was associated with
a significantly higher risk (OR 43.77) of
IANI. These results indicate that the CT
findings may predict the development of
IANI more accurately than the panorama
findings. Recently, Renton et al. described
a radiological feature known as ‘the juxta-
apical area’ and suggested that it was
predictive of an increased risk of IANI.20
Therefore, we should consider this poten-
tial predictive feature in future studies. An
enhanced understanding of the anatomical
relationship may necessitate an alteration
of the surgical approach for removal of the
tooth, or allow the surgeon to plan an
alternative risk-reducing surgical techni-
que, for example, coronectomy.20,37
However, because of the different
socioeconomic conditions in many coun-
tries, the high cost of CT scans, and the
amount of radiation used for CT, panora-
mic radiography may be regarded as the
acceptable method in preoperative radi-
ologic evaluation. One obvious drawback
of CT is the higher dose of radiation that
the patient receives compared with con-
ventional radiography. The routine use of
CT scanning as a diagnostic method is
currently constrained due to the relatively
high radiation dose, as well as the time and
labour required to complete the procedure,
and also due to the resulting cost implica-
tions. Therefore, when the panoramic
image is suggestive of an intimate rela-
tionship between the impacted tooth and
the mandibular canal, CT is recommended
for further investigation to clarify the
three-dimensional relationship between
the two structures.
850 Hasegawa et al.
In conclusion, we successfully demon-
strated the multivariate relationships
among various risk factors and IANI,
and the differences between the preopera-
tive imaging findings on panoramic radio-
graphs and CT images. Many panoramic
findings were not consistent with the CT
findings (275 teeth; 62.5%). Therefore,
panoramic radiography alone does not
provide sufficiently reliable images
required for predicting nerve lesions. As
a result, when the panoramic image is
suggestive of an intimate relationship
between the impacted tooth and the man-
dibular canal, CT is recommended for
further investigation.
Funding
None.
Competing interests
None declared.
Ethical approval
This was a non-randomized, retrospective
(historic) cohort study of patients. Thus,
this study was granted exemption from
institutional review board approval by
our institution.
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Tel: +81 78 382 6213; Fax: +81 78 351 6229
E-mail: hasetaku@med.kobe-u.ac.jp
Address:
Takumi Hasegawa
Department of Oral and Maxillofacial