A comparative study of cone-beam computed tomography and conventional panoramic radiography in assessing the topographic relationship between the mandibular canal and impacted third molars

Radiographic Predictors of Postoperative Inferior Alveolar Nerve Injury in Mandibular Third Molar Surgery

BACKGROUND

Cone-beam computed tomography (CBCT) provides additional 3-dimensional information on the relationship between the mandibular third molar (M3M) and the inferior alveolar nerve (IAN). As such, CBCT is being increasingly utilized in preoperative M3M assessment.

PURPOSE

The purpose of the study was to compare the radiographic findings on panoramic and CBCT and their association with postoperative IAN paresthesia.

STUDY DESIGN, SETTING, SAMPLE

We conducted a retrospective cohort study in a sample of patients referred to the Department of Oral and Maxillofacial Surgery at the Royal Dental Hospital of Melbourne, for management of impacted M3Ms. Patients were included in this study if they had 1 or more high-risk findings on orthopantomogram (OPG), had both OPG and CBCT imaging taken and if at least 1 M3M had been extracted. Subjects were excluded from this study if their M3Ms were not extracted or if a CBCT was not indicated.

INDEPENDENT VARIABLE

The independent variable was radiographic features identified on OPG (Rood and Shehab's radiographic signs, root morphology, impaction type, Pell and Gregory classification) and CBCT (number and location of roots, severity of IAN compression and the presence of ankylosis).

MAIN OUTCOME VARIABLE

The outcome variable was postoperative neurosensory function defined as any reported paresthesia at 2-week postprocedural review.

COVARIATES

The covariates were patient demographic information (age, sex).

ANALYSES

Variables were initially assessed with univariate logistic regression analysis to determine factors related to developing postoperative paresthesia. Multivariate logistic regression analysis was then used to assess the association between positive univariate study variables and postoperative paresthesia, while adjusting for potential confounders. Covariates were assessed using an omnibus likelihood ratio test and included if they were statistically significant at the P < .05 level.

RESULTS

The study sample consisted of 257 subjects who underwent surgical removal of n = 386 M3Ms. The mean age was 25.9 (SD = 7.05). The panoramic features of narrowing of canal, diversion of canal and dark/bifid roots were identified as statistically significant associations of postoperative paresthesia. No CBCT features were significantly associated of postoperative paresthesia.

CONCLUSION AND RELEVANCE

Certain panoramic features, along with patient age, are significant predictors of IAN paresthesia. CBCT findings were not significant predictors upon multivariate analysis, thus additional CBCT imaging did not significantly improve ability to predict paresthesia.

A 3D-Planned Inward Fragmentation Technique for the Removal of Impacted Mandibular Third Molars: A Case Series

Background/Objectives: The extraction of impacted mandibular third molars (M3Ms) carries significant risks, especially regarding the inferior alveolar nerve (IAN). This study aimed to evaluate the effectiveness of a 3D-planned inward fragmentation technique (3Dp-IFT) to improve surgical outcomes, reduce complications, and preserve bone structure in cases involving complex M3M impactions. Methods: Twenty-three patients aged between 18 and 36 years requiring M3M removal were included. Preoperative planning involved the use of cone-beam computed tomography (CBCT) for precise localization of the furcation area, followed by the creation of a 3D navigation template using PlastyCAD software version 1.7. The surgical procedure was performed under local anesthesia, with meticulous endoscopic assistance to ensure accurate access and minimize trauma. Postoperative outcomes, such as bone loss, pain, swelling, and mouth opening range, were carefully measured. The data were systematically organized and analyzed descriptively using Microsoft Excel. Results: No disturbances to the IAN or lingual nerve were observed. The mean buccal bone loss was 2.2 mm, with a standard deviation of 1.2 mm. Postoperative pain and swelling were generally low, with significant reductions within the first week. The use of the 3D navigation template significantly improved surgical access, enhancing safety and minimizing complications. Conclusions: The 3Dp-IFT technique represents a significant advancement in the minimally invasive removal of M3M by allowing precise access to critical anatomical areas while minimizing bone loss and postoperative complications. This approach is particularly beneficial for complex cases involving M3M near the IAN, thereby improving surgical safety and patient outcomes.

Protocol for Diagnostic Test Accuracy Study: Evaluation of Cone Beam Computed Tomography (CBCT) in Prediction of Inferior Alveolar Nerve Injury as Compared to Orthopantomography (OPG) Secondary to Surgical Removal of Impacted Mandibular Third Molars

Introduction Impairment of the inferior alveolar/dental nerve (IAN) is a relatively uncommon complication after lower wisdom tooth removal. Studies report varying incidences of IAN injury, with dysesthesia being noted as particularly distressing and 0-0.9% cases extending for a long duration. Neurosensory disruptions can severely impact speech, chewing, swallowing, and social interactions, leading to chronic pain and a lower quality of life. It also poses a risk of inadvertent injuries during meals. Although orthopantomogram (OPG) is primarily used for diagnosis, but when the lower wisdom tooth and nerve are in close approximation, cone beam computed tomography (CBCT) is recommended, despite its higher cost and radiation exposure. A white paper on third molar management necessitates further research on CBCT's role, citing conflicting evidence. Further in a multicentric trial, the difference between the OPG versus CBCT group was not statistically significant due to the low incidence of IAN injuries. They have emphasized the need for more well-designed studies to reach a statistically significant conclusion by meta-analyses. Hence, this study aims to provide additional evidence. Methods It is a two-arm, parallel, diagnostic study design involving individuals between the ages of 18 and 50 years, requiring lower wisdom tooth removal that is closely approximated with the nerve. Eligible adults, based on the specified inclusion/exclusion criteria, will be recruited into the study; informed consent will be obtained; then assigned randomly to the OPG or CBCT group using a random computer-generated sequence. Extractions will be done under local anesthesia using a standard surgical protocol with odontectomy. Surgical variables will include the experience of the surgeon, amongst others. The outcome variables will be recorded using patient interviews (subjective) and objective examinations from day one up to six months after surgery. The primary outcome will comprise the number of patients reporting abnormal sensations post-surgery. Secondary outcomes will include objectively confirmed IAN injuries and permanent IAN injuries (>6 months). Results will be analyzed statistically to look for significance and possible risk factors associated with it. Results If a statistically significant result is obtained, then we can deliberately reduce CBCT referrals and reserve them only for high-risk cases, wherein the risk of IAN injury cannot be predicted by OPG alone. If the experience of the surgeon proves to be an important risk factor, then it can also help refer high-risk patients to surgeons with more experience. Conclusion If CBCT proves to be statistically superior to OPG in the prediction of nerve injury, then we will be able to avoid significant morbidity and improve the quality of life of such patients by either modifying the surgical steps or by choosing other conservative treatment modalities. Further, this may reduce unnecessary CBCT referrals, thus reducing radiation exposure, the cost to patients, and, in turn, national healthcare expenditure. Besides, CBCT is not available at all centers, so a lot of low-risk patients can be managed safely at primary health centers, thus reducing the urban patient load.

Exploring Technological Progress in Three-Dimensional Imaging for Root Canal Treatments: A Systematic Review

INTRODUCTION AND AIMS

Root canal therapy is a crucial aspect of endodontic treatment aimed at preserving natural dentition. Over the years, advancements in three-dimensional (3D) technology have revolutionized diagnosis and treatment planning. Different 3D technologies are used in dental care, such as cone-beam computed tomography (CBCT), which ensures 3D slice visualization, root canal microanatomy, and dynamic navigation throughout the pulp cavity. By exploring the latest technological progress in this field, we seek to understand how these innovations are enhancing precision, efficiency, and patient outcomes, shedding light on the benefits and potential impact of 3D imaging in improving root canal procedures.

METHODS

Literature was searched from different databases, including PubMed, ScienceDirect, The Cochrane Library, Scopus, and Google Scholar. Inclusion criteria involved studies on 3D technology in root canal therapy with comparison groups, including RCTs and non-RCTs. Excluded studies lacked 3D imaging advancements, a control group, or were review articles or case studies. Quality assessment utilized QUIN for in vitro studies and ROBINS-I for non-RCTs to evaluate the studies' validity.

RESULTS

According to the PRISMA guidelines, among 5015 initial articles, 16 were included. CBCT was the most used 3D imaging technique for root imaging followed by micro-computed tomography (MCT) and limited CBCT (LCBCT) imaging methods. 2D radiographs and 2D histological methods and clearing techniques were the most common comparative modalities. Overall, 3D imaging streamlined dental treatment as clinicians could visualize much clearer and higher-quality images. Different resolutions and voxel sizes were applied to improve imaging quality.

CONCLUSION

Three-dimensional imaging, especially CBCT, improves root canal treatments by providing superior image quality. CBCT outperforms other techniques like MCT and LCBCT, enhancing clarity. Varying resolutions and voxel sizes optimize the effectiveness of 3D imaging in root canal therapy.

CLINICAL RELEVANCE

The advancements in 3D imaging technology, particularly CBCT, have significantly enhanced the diagnosis and treatment planning for root canal therapy. CBCT provides detailed insights into intricate root canal anatomy, improving diagnostic accuracy.

Investigation of the relationship between the mandibular third molar teeth and the inferior alveolar nerve using posteroanterior radiographs: a pilot study

BACKGROUND

The most severe complication that can occur after mandibular third molar (MM3) surgery is inferior alveolar nerve (IAN) damage. It is crucial to have a comprehensive radiographic evaluation to reduce the possibility of nerve damage. The objective of this study is to assess the diagnostic accuracy of panoramic radiographs (PR) and posteroanterior (PA) radiographs in identifying the association between impacted MM3 roots and IAN.

METHODS

This study included individuals who had PR, PA radiographs, and cone beam computed tomography (CBCT) and who had at least one impacted MM3. A total of 141 impacted MM3s were evaluated on CBCT images, and the findings were considered gold standard. The relationship between impacted MM3 roots and IAN was also evaluated on PR and PA radiographies. The data was analyzed using the McNemar and Chi-squared tests. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of PR and PA radiographies were determined.

RESULTS

Considering CBCT the gold standard, the relationship between MM3 roots and IAN was found to be statistically significant between PR and CBCT (p = 0.00). However, there was no statistically significant relationship between PA radiography and CBCT (0.227). The study revealed that the most prevalent limitation of the PR in assessing the relationship between MM3 roots and IAN was the identification of false-positive relationship.

CONCLUSIONS

PA radiography may be a good alternative in developing countries to find out if there is a contact between MM3 roots and IAN because it is easier to get to, cheaper, and uses less radiation.

Relationship between Impacted Mandibular Third Molars and the Mandibular Canal on CBCT Scans

This study aimed to assess the relationship of impacted mandibular third molars with the mandibular canal on cone beam computed tomography (CBCT) scans. This cross-sectional study was conducted on CBCT scans of 137 patients with 204 impacted mandibular third molars. The relation of age, gender, class of impaction, anatomical position of canal relative to tooth (buccal, lingual, inferior, inter-radicular), tooth angulation (mesioangular, vertical, distoangular, horizontal), relationship of tooth with the mandibular canal (no contact, in contact, relation), relationship of tooth with the mandibular cortex, anatomical site of contact of tooth with the mandibular cortex (buccal, lingual, inferior), and the impression of canal (grooving, no effect) on impacted teeth were evaluated. Data were analyzed using one-way ANOVA, Chi-square test and Fisher's exact test. Class B of impaction (78.9%), inferior position of canal relative to the impacted tooth (53.9%) and mesioangular angulation (53.4%) had the highest frequency, respectively. The relationship of tooth with the mandibular canal was "relation" in most cases (53.4%) followed by no contact (26.9%) and in contact (19.6%). Significant associations were noted between depth of impaction (P < 0.001), tooth angulation (P = 0.024), anatomical position of canal relative to tooth (P < 0.001), relationship of tooth with the mandibular cortex (P = 0.032) and anatomical site of contact of tooth with the mandibular cortex (P = 0.013) with the impacted tooth-mandibular canal relationship. CBCT provides accurate information about the relationship of impacted third molars with the mandibular canal and can decrease the risk of traumatization of inferior alveolar nerve (IAN) during their surgical extraction.

Three-dimensional positional relationship between impacted mandibular third molars and the mandibular canal

OBJECTIVE

To observe the three-dimensional positional relationship between impacted mandibular third molars (IMTMs) and mandibular canal close contacts using cone beam computed tomography (CBCT).

METHODS

A total of 101 patients with IMTMs were selected who met the diagnostic criteria for 142 teeth (no bone wall imaging area between IMTMs and the mandibular canal, a high-density bone cortical imaging area only, or a ≦1 mm bone imaging area). The parameters of the rotating CBCT anode were set as follows: 110 kV, 40-50 mA; the focal point and exposure field were set as 0.3 mmh and a high-resolution zoom, respectively; the exposure time and image layer thickness were set as 5.4 s and 0.25 mm. Three-dimensional reconstruction was performed, and the position of the mandibular canal through the IMTM area was observed continuously from the coronal, horizontal and sagittal planes.

RESULTS

We found that the mandibular canal was interrupted below the third molar (TM) in 85 cases, accounting for 59.86% of all cases. The mandibular canal was located below the buccal and lingual curvatures in 33 and 19 cases, respectively, accounting for 23.23% and 19%. In addition, a small number of mandibular canals were also located on the buccal side of the mandibular molars (2.82%). We also found one case of direct insertion of the mandibular third molar (MTM) into the mandibular canal. In addition, the mandibular canal passed through the IMTM region with 125 close contacts at the roots (88.03%); 14 mandibular canals were in contact with all teeth and 3 were in contact with the crown.

CONCLUSION

The use of CBCT can provide a dynamic and comprehensive understanding of the three-dimensional positional relationship of the mandibular alveolar nerve canal passing through the IMTM area, providing a high clinical reference value when extracting IMTMs and reducing the risk of injury to the inferior alveolar nerve.

Identification of the inferior alveolar canal using cone-beam computed tomography vs. panoramic radiography: a retrospective comparative study

BACKGROUND

This study aims at evaluating the visibility levels of the inferior alveolar canal (IAC) at different mandibular sites using panoramic (conventional & CBCT reformatted) and CBCT coronal views in a sample of a Palestinian population.

METHODS

The panoramic (conventional [CP] & CBCT reformatted [CRP]) and CBCT coronal views (CCV) of 103 patients (206 records, right and left sides) were analyzed. The visibility of IAC at five sites extending from the first premolar to the third mandibular molar region was evaluated visually (and compared among the radiographic views) as clearly visible, probably visible, invisible/poorly visible, or not present at the examined site. On CCV, the maximum dimension of the IAC (MD), the vertical distance (VD) between the mandibular cortex and IAC, and the horizontal position (HP) of the IAC were noted. Statistical significance in the differences and relationships of the variables was tested using several statistical tests.

RESULTS

There was a statistically significant relationship between the radiography modality (CP, CRP, CCV) and the visibility level of IAC (assessed in scores) at the five mandibular sites. When assessed on CP, CRP, and CCV, the IAC was clearly visible at all sites in 40.4%, 30.9%, and 39.6%, respectively, while being invisible/poorly visible in 27.5%, 38.9%, and 7.2% for the same views, respectively. The mean values of MD and VD were 3.61 mm and 8.48 mm, respectively.

CONCLUSION

Different radiographic modalities would characterize the IAC's structure in different qualities. Superior visibility levels were obtained interchangeably using CBCT cross-sectional views and conventional panorama at different sites compared to CBCT reformatted panorama. The IACs visibility was noted to improve at their distal aspects irrespective of the radiographic modality used. Gender -but not age- was a significant factor in the visibility level of IAC at only two mandibular sites.

Application of Cone Beam Computed Tomography in Risk Assessment of Lower Third Molar Surgery

Risks of lower third molar surgery like the inferior alveolar nerve injury may result in permanent consequences. Risk assessment is important prior to the surgery and forms part of the informed consent process. Traditionally, plain radiographs like orthopantomogram have been used routinely for this purpose. Cone beam computed tomography (CBCT) has offered more information from the 3D images in the lower third molar surgery assessment. The proximity of the tooth root to the inferior alveolar canal, which harbours the inferior alveolar nerve, can be clearly identified on CBCT. It also allows the assessment of potential root resorption of the adjacent second molar as well as the bone loss at its distal aspect as a consequence of the third molar. This review summarized the application of CBCT in the risk assessment of lower third molar surgery and discussed how it could aid in the decision-making of high-risk cases to improve safety and treatment outcomes.

Does the addition of cone-beam CT to panoral imaging reduce inferior dental nerve injuries resulting from third molar surgery? A systematic review

Objective

This systematic review aims to examine whether cone-beam CT (CBCT) assessment influences the incidence of nerve injury following high-risk mandibular third molar (MTM) surgery.

Study Design

Randomised controlled trials comparing two and three-dimensional imaging for assessing high-risk MTMs were included. MEDLINE, EMBASE, CENTRAL and the Dentistry and Oral Science Source (DOSS) were systematically searched along with extensive grey literature searches, hand searching of web sites, and detailed citation searching up to 3 September 2022. Risk of bias was assessed against the Cochrane Risk of Bias Tool (RoB 2.0). Certainty of the evidence was assessed using GRADE.

Results

Two authors independently screened 402 abstracts prior to full text screening of 27 articles, which culminated in seven RCTs for inclusion. Two studies were assessed as high risk of bias overall. The other five raised some concerns largely due to unblinded patients and lack of prior trial registration. Just one study reported significantly less nerve injuries following CBCT. The remaining six articles found no significant difference.

Conclusion

The seven RCTs included in this systematic review offered moderate quality evidence that CBCT does not routinely translate to reduced incidence of nerve injury in MTM removal. A single study provided low quality evidence for a consequent change in the surgical approach. Low quality evidence from 3 studies suggested CBCT does not influence the duration of third molar surgery.

Top 100 cited publications in the field of third molar surgery: A bibliometric analysis

This study aimed to identify and rank the top 100 cited papers related to third molar surgery METHODS: This bibliometric analysis was performed through the Clarivate Analytics' Web of Science database intended to find the top 100 most cited papers. The search was conducted on 18^th November 2021 with MeSH terms related to the third molar surgery. Extracted Data included title, main author, institution, publication year, a total of citations, citation average per year, country, the journal paper was published, journal impact factor, the number of citations of the three most-cited journals, study design, and field related to third molar surgery RESULTS: The top-cited paper was a retrospective cohort related to complications after the third molars surgery, published in 2003 in the Journal of Oral and Maxillofacial Surgery. The total number of citations was 9026. Thirty-nine percent of the papers included were randomized clinical trials. The USA is the main country responsible for the best publications in the field of third molar surgery. European researchers had the main expressive citation score, and "surgery" related to the third molar was the most critical field of research CONCLUSIONS: 1) The United States of America was the leading country that contributed to third molar field research 2) The Universities of Barcelona and the University of North Carolina were the most productive institutions regarding this research field; 3) Complications after third molar surgery was the most researched field. Compared to the other fields in dentistry such as Oral pathology and Cariology, the number of citations regarding third molar surgery was low.

Prevalence and Characteristics of Accessory Mandibular Canals: A Cone-Beam Computed Tomography Study in a European Adult Population

The purpose of this observational study is to evaluate the prevalence and main characteristics of bifid canals within a European adult population, analyzing cone-beam-computed tomography (CBCT). The population study examined 300 subjects. The CBCTs were performed between 2012 and 2019, using PaX-Zenith3D with a standard protocol of acquisition. The parameters analyzed were the presence and lengths of the bifid mandibular canals. The sample included 49% male and 51% female participants. The mean age of the patients was 47.07 ± 17.7 years. Anatomical variants of the mandibular canal were identified in 28.8% of the sides and 50.3% of the patients. In 7.3% of the subjects, the anatomical variants were present bilaterally. The most frequently encountered bifid canal was Type 3 (40.5%), followed by the Type 1 canal (39.3%), the Type 2 canal (14.5%), and the Type 4 canal (5.9%), 40% on the right side and 60% on the left side. The average length of the bifid canals located on the right side of the mandible was 11.96 ± 5.57 mm, compared to 11.38 ± 4.89 mm for those measured on the left side. The bifid mandibular canal is a common anatomical variation of the mandibular canal. It is fundamental to performing an accurate preoperative evaluation using CBCT analysis to avoid and/or reduce intraoperative and postoperative complications.

Can CBCT change the level of confidence of oral maxillofacial surgeons in mandibular third molar management?

This study analyzed the impact of CBCT on the level of confidence in diagnostic and treatment thinking in mandibular lower molar (M3M) clinical management. Thirty cases for which panoramic radiographs and CBTC images were available were selected and classified according to radiologic signs indicating the proximity of the M3M to the mandibular canal (interruption of the radiopaque borders of the canal of the mandibular canal wall, darkening of the roots, and diversion or narrowing of the canal, n = 10 for each classification). Twelve oral and maxillofacial surgeons (OMS) contributed to this study by answering two questionnaires. The first questionnaire contained a clinical description of the case and a panoramic radiograph. After 30 days, a second questionnaire with the same clinical illustrations and tomographic multiplanar reconstruction images was administered. Both questionnaires asked specialists to rate diagnostic confidence, the surgical complexity, chosen treatment, and surgical confidence. In approximately 40% of answers, CBCT images had a positive impact on ratings of diagnostic confidence and treatment thinking confidence, and in 24.4%, they increased the surgical complexity score. There was no change in the treatment plan following the use of CBCT, but the CBCT examination was a determining factor for diagnosis and treatment planning in 72.8% of the answers CBCT improved the confidence level in diagnostic and treatment thinking of the M3M management while also increasing the perceived level of surgical complexity. The findings of this study support the need to consider using CBCT in diagnosis and treatment planning for M3Ms with radiographic signs such as darkening of the roots, interruption of the radiopaque borders of the mandibular canal, or deviation of the mandibular canal and narrowing of the roots.

The Importance of Correlation between CBCT Analysis of Bone Density and Primary Stability When Choosing the Design of Dental Implants—Ex Vivo Study

This study aims to determine the correlation between the mean value of bone density measured on the CBCT device and the primary stability of dental implants determined by resonant frequency analysis. An experimental study was conducted on a material of animal origin: bovine femur and pig ribs. Two types of implants were used in this study: self-tapping and non-self-tapping of the same dimensions. Results of the experimental study showed a statistically significant correlation between bone density expressed in HU units and the primary stability of self-tapping and non-self- tapping dental implants expressed in ISQ units in bovine femur bones and self-tapping implants and pig rib bones. There was no statistically significant correlation between non-self-tapping dental implants in pig rib bones. Self-tapping and non-self-tapping implants did not show statistical significance in the primary stability in bones of different qualities. The analysis of bone density from CBCT images in the software of the apparatus expressed in HU units can be used to predict the degree of primary stability of self-tapping and non-self-tapping dental implants in bones of densities D1 and D2, and self-tapping dental implants in bones of the lower quality D4.

Comparison of Digital OPG and CBCT in Assessment of Risk Factors Associated with Inferior Nerve Injury during Mandibular Third Molar Surgery

Background: Pre-operative radiographic assessment of the anatomical relationship between the roots of the mandibular third molar and the inferior alveolar nerve (IAN) is a must to minimize the risk of IAN injury during surgery. Objectives: To compare the radiographic signs of digital orthopantomogram (OPG) and cone-beam computed tomography (CBCT). An additional objective was to assess the cortex status between the mandibular canal and third molar on CBCT images in relation to the demographic characteristics, region (right or left side), and angulation of mandibular molar. Methodology: In this retrospective study, a total of 350 impacted mandibular third molars with a close relationship between the inferior alveolar canal (IAC) and impacted mandibular third molars on digital OPG were further referred for CBCT imaging for assessment of the position of the mandibular canal. The study was conducted between August 2018 and February 2020. Digital OPGs were evaluated for radiographic signs like interruption of the mandibular canal wall, darkening of the roots, diversion of the mandibular canal, and narrowing of the mandibular canal. The age and sex of patients, site of impacted third molar, Winter’s classification of mandibular third molar, position of IAC relative to impacted molar, and the radiographic markers of OPG were assessed for cortical integrity using CBCT. Chi square testing was applied to study the values of difference and binomial logistic regression was done to assess the factors associated with cortication. Statistical significance was set at p ≤ 0.05. Results: Among 350 patients, 207 (59.1%) were male and 143 (40.9%) were female with a mean age of 36.8 years. The most common OPG sign was interruption of white line, seen in 179 (51.1%) cases. In total, 246 cases (70.3%) showed an absence of canal cortication between the mandibular canal and the impacted third molar on CBCT images. Cortication was observed in all cases with a combination of panoramic signs which was statistically significant (p = 0.047). Cortication was observed in 85 (50.6%) cases where IAC was positioned on the buccal side, 11 (16.9%) in cases of inferiorly positioned IAC, and just 8 (7.6%) for cases of lingually positioned IAC which was statistically significant (p = 0.003). Statistically insignificant (p > 0.05) results were noted for cortex status in CBCT images with regards to the age, sex, site, and angulation of impacted third molars. Conclusion: CBCT imaging is highly recommended for those cases where diversion of the mandibular canal is observed on OPG and when the roots are present between canals.

Clinical Significance of Intraoperative Exposure of Inferior Alveolar Nerve during Surgical Extraction of the Mandibular Third Molar in Nerve Injury

During extraction surgery, the inferior alveolar nerve (IAN) can occasionally be observed in the extraction socket of the mandibular third molar (M3). The purpose of this study was to investigate and compare the incidence of IAN injury in groups with and without intraoperative IAN exposure during surgical extraction of M3, and to identify additional risk factors for the IAN injury in addition to the IAN exposure. A total of 288 cases in 240 patients, who underwent surgical extraction of M3 by a single surgeon, were divided into the exposed group (n = 69) and the unexposed group (n = 219). The surgeon recorded the information regarding the procedure when the clinical observation of IAN exposure was made during the surgery. The incidence of IAN injury after the extraction surgery was significantly higher in the exposed group than in the unexposed group (4.3% versus 0%, p < 0.05). Paresthesia was recognized in three cases of the exposed group, but it showed complete recovery within three postoperative months. No case of permanent paresthesia was detected in both groups. According to the logistic regression, the only significant risk factor of IAN injury in the exposed group was the increase of age (OR 1.108, p < 0.05). Intraoperative IAN exposure during surgical extraction of M3 may show a higher incidence of IAN injury than the case without IAN exposure, representing an incidence of 4.3%. Even if the paresthesia associated with IAN exposure occurs, it is likely to be a temporary injury, and this risk may increase with age.

Retrospective evaluation of sensory neuropathies after extraction of mandibular third molars with confirmed "high-risk" features on cone beam computed topography scans

OBJECTIVES

The objective of this study was to identify the incidence of inferior alveolar nerve (IAN) injury after extraction of mandibular third molars with confirmed "high-risk" features on cone beam computed topography scans and establish any risk factors that significantly increase the chances of sustaining an IAN injury.

STUDY DESIGN

This study is a retrospective analysis of outcomes after surgical extraction of 500 mandibular third molars over a 5-year period. All teeth showed signs of contact with or compression of the IAN on cone beam computed topography scans.

RESULTS

The overall incidence of IAN injury was 6.6%, with permanent neuropathies accounting for 1.8% within this high-risk cohort. Statistically significant factors shown to increase the risk of nerve injury included increasing age (P = .002), compression of the nerve evident on cone beam computed topography scan (P = .005), and buccal or interradicular position of the nerve (P = .042).

CONCLUSIONS

Results indicate a low incidence of IAN injury, particularly given the high-risk nature of all teeth that were extracted. It highlights the benefits of cone beam computed topography scans in surgical planning. These data are an important contribution to the existing literature and valuable in the consent procedure for patients undergoing surgical removal of mandibular third molars in contact with the IAN.

Positive Predictive Value of Panoramic Radiography for Assessment of the Relationship of Impacted Mandibular Third Molars with the Mandibular Canal Based on Cone-Beam Computed Tomography: A Cross-Sectional Study

The aim of the present study was to assess the positive predictive value (PPV) of panoramic radiographic signs in the assessment of the relationship between impacted mandibular third molars (IMTMs) and the mandibular canal (MC). This cross-sectional study was conducted by reviewing 102 cone-beam computed tomography (CBCT) and panoramic radiographs of patients with IMTMs and radiographic signs of the contact of the IMTMs with the MC on panoramic radiographs (i.e., root apex darkening and interference with the white line). A positive relationship of the IMTM roots with the MC based on CBCT findings was recorded as the gold standard. The PPV of panoramic radiographic signs was calculated for the detection of the relationship of the IMTM root with the MC. The IMTMs were in contact with the MC on CBCT scans in 90.1% of the cases. The PPV of root apex darkening and the interference with the white line was found to be 89.09% (95% CI: (77.75, 95.88)) and 91.48% (95% CI: (79.62, 97.63)), respectively. The MC had a buccal position in 63.7%, and a lingual position in 35.2%, of the cases. The contact of IMTMs with the MC was more commonly seen in patients with a lingual position (100% of the samples). The IMTM root apex darkening and interference with the white line of the MC on panoramic radiographs had a high PPV for determination of the contact of IMTMs with the MC. Thus, presence of the above-mentioned risk factors indicates the need for subsequent 3D radiographic assessments.

Inferior alveolar nerve damage secondary to orthodontic treatment: A systematic scoping review

BACKGROUND

Neurosensory impairment is a common complication following inferior alveolar nerve (IAN) damage.

OBJECTIVE

To document and report the various causes, diagnosis, and management of IAN damage secondary to orthodontic treatment.

METHODS

An electronic search for studies that reported IAN damage in patients undergoing orthodontic treatment was performed up to July 15, 2020 using MEDLINE, Embase, and PubMed databases. Descriptive analyses and linear regression model were performed.

RESULTS

A total of 15 case reports were identified including 16 patients with an overall mean age of 23.3. All the included studies reported temporary sensory alterations which manifested as anesthesia (19%, n = 3), paresthesia (75%, n = 12), or combined (6%, n = 1). The majority of cases managed by stopping the orthodontic force (75%, n = 12), followed by appliance adjustments (19%, n = 3), providing a bite plate (13%, n = 2), and/or providing pharmacological management (38%, n = 6). Full recovery median duration reported in all cases following the aforementioned managements was 17.5 days.

CONCLUSIONS

IAN damage secondary to orthodontic treatment is emerging in the literature in recent years. Identifying high risk patients with close proximity to the IAN canal is a must to formulate a proper treatment plan to avoid such complications.

Deep learning-based evaluation of the relationship between mandibular third molar and mandibular canal on CBCT

OBJECTIVES

The objective of our study was to develop and validate a deep learning approach based on convolutional neural networks (CNNs) for automatic detection of the mandibular third molar (M3) and the mandibular canal (MC) and evaluation of the relationship between them on CBCT.

MATERIALS AND METHODS

A dataset of 254 CBCT scans with annotations by radiologists was used for the training, the validation, and the test. The proposed approach consisted of two modules: (1) detection and pixel-wise segmentation of M3 and MC based on U-Nets; (2) M3-MC relation classification based on ResNet-34. The performances were evaluated with the test set. The classification performance of our approach was compared with two residents in oral and maxillofacial radiology.

RESULTS

For segmentation performance, the M3 had a mean Dice similarity coefficient (mDSC) of 0.9730 and a mean intersection over union (mIoU) of 0.9606; the MC had a mDSC of 0.9248 and a mIoU of 0.9003. The classification models achieved a mean sensitivity of 90.2%, a mean specificity of 95.0%, and a mean accuracy of 93.3%, which was on par with the residents.

CONCLUSIONS

Our approach based on CNNs demonstrated an encouraging performance for the automatic detection and evaluation of the M3 and MC on CBCT. Clinical relevance An automated approach based on CNNs for detection and evaluation of M3 and MC on CBCT has been established, which can be utilized to improve diagnostic efficiency and facilitate the precision diagnosis and treatment of M3.

Diagnostic accuracy of CBCT compared to panoramic radiography in predicting IAN exposure: a systematic review and meta-analysis

OBJECTIVES

The aim of this study is to verify whether the diagnostic accuracy of cone beam computed tomography (CBCT) is superior to panoramic radiography (PR) in predicting inferior alveolar nerve (IAN) exposure during the lower third molar extraction.

MATERIALS AND METHODS

Eight electronic databases were searched up to September 2020. Studies that evaluated the accuracy (sensitivity, specificity, positive-predictive value, and negative predictive value) of both imaging methods were included. The gold standard was the visualization of the IAN exposure during the extraction of lower third molars. The gray literature was also used to include any other paper that might meet the eligibility criteria. The meta-analysis was performed with OpenMeta-Analyst and ReviewManager v.5.3 software. The methodology of the studies was evaluated using QUADAS-2.

RESULTS

Among the search, three studies met all the eligibility criteria and were included in the qualitative and quantitative synthesis. The meta-analysis was conducted with all included studies. Accuracy values for CBCT were 95.1% for sensitivity (p=0.666) and 64.4% for specificity (p<0.001). For PR sensitivity and specificity, we observed 73.9% (p=0.101) and 24.8% (p<0.001), respectively.

CONCLUSIONS

Both exams were reliable for detecting positive cases of exposure of the IAN. However, CBCT had a better performance compared to PT in predicting IAN exposure during surgery.

CLINICAL RELEVANCE

To better understand the CBCT accuracy in predicting the IAN exposure during surgery, since this event can increase the likelihood of IAN injury and, consequently, cause neurosensory disturbances.

Panoramic prediction equations to estimate implant- to-mandibular canal dimensions in the mandibular posterior region: implications for dental implant treatment

Background

To develop and cross-validate site-specific panoramic radiography (PAN) analysis prediction equations of implant-to-mandibular canal dimensions (IMCD) in mandibular regions posterior to the mental foramen, and to help determine in which instances CBCT technology will be a justified adjunct in clinical practice.

Methods

IMCD by PAN (Pan-D) from implant site-specific regions (first premolar, second premolar, first molar, and second molar sites) were collected from 40- to 70-year-old adolescents. They were randomly assigned to validation (n = 144) and cross-validation (n = 148) groups. The cone-beam computed tomography (CBCT) technique was used as the criterion method for the estimation of IMCD (CBCT-D). The PAN analysis equations were developed using stepwise multiple regression analysis and cross-validated using the Bland–Altman approach.

Results

There was a significant relationship between PAN-D and CBCT-D for both validation (R² = 57.8 %; p < .001) and cross-validation groups (R² = 52.5 %; p < .001). Root means-squared error (RMSE) and pure error (PE) were highest for the first molar (RMSE = 1.116 mm, PE = 1.01 mm) and the second molar region (RMSE = 1.162 mm, PE = 1.11 mm).

Conclusions

PAN-D has the potential to be developed as an indirect measure of IMCD. However, the findings suggest to exclude scoring of the first and second molars when assessing IMCD via PAN. Use of CBCT may be justified for all IMCD estimations in the first and second molars regions.

Trial registration

This study has been registered and approved by the Ethics Committee of the Martin-Luther University, Halle, Germany (2020-034).

Radiographic Position of Impacted Mandibular Third Molars and Their Association with Pathological Conditions

Objectives

This study aimed to assess the radiographic position of impacted mandibular third molars (IMTMs) and their association with pathological conditions.

Materials and Methods

The impaction depth, relationship with ramus, and angulation of 1600 IMTMs and their association with 2^nd molar distal caries and root resorption, pathological conditions, and proximity to the mandibular canal were evaluated on panoramic radiographs. The IMTM position was determined based on the depth of impaction according to the Pell and Gregory classification, relationship with ramus according to the Pell and Gregory classification, and angulation according to the Winter's classification. The classical and Bayesian logistic regressions were applied to analyze the effect of IMTM position on the associated complications using the odds ratio (OR) and 95% confidence interval (credible interval for Bayesian models). Two-tailed P value < 0.05 was considered statistically significant.

Results

Of 1600 IMTMs evaluated in this study, 195 (12.2%), 252 (15.8%), and 119 (7.4%) had caused second molar distal caries, second molar root resorption, and pathological lesions, respectively, and 872 (54.5%) had contact with the mandibular canal. Impaction angulation was a risk factor for second molar distal caries (maximum OR = 5.01, 95% CI: 3.12-8.18). Changed angulation and greater impaction depth were the risk factors for second molar root resorption (minimum OR = 1.64, 95% CI: 0.58-4.02). Decreased distance between the ramus and distal side of the second molar was a risk factor for associated pathological lesions (minimum OR = 2.73, 95% CI: 1.79-4.25). Mesioangular and horizontal angulations and greater impaction depth were the risk factors for contact with the mandibular canal (maximum OR = 3.44, 95% CI: 2.6-4.57 and minimum OR = 1.3, 95% CI: 094-1.8).

Conclusions

The frequency of complications associated with IMTMs was low, but considerable. The occurrence of these conditions might be affected by the impaction position. Thus, regular follow-ups are recommended in order to be able to surgically intervene when the first signs of pathologies arise.

Telemedicine for a Multidisciplinary Assessment of Orofacial Pain in a Patient Affected by Eagle’s Syndrome: A Clinical Case Report

Background:

Orofacial pain has a broad range of origins and a multidisciplinary approach occupies a relevant role.

Objective:

The aim of this study was to review the literature regarding the evolution of telemedicine and orofacial pain related to a case report of a patient affected by Eagle's syndrome.

Materials and Methods:

Two authors (RJM and SG) independently reviewed the literature up to March 2020. A case report was developed by including the interdisciplinary assessment and initial treatment of orofacial pain in a 38-year-old female patient affected by Eagle’s syndrome. The patient was interviewed by two different specialists (from Rome, Italy and Los Angeles, California) through an online meeting platform in order to evaluate her complex situation, demonstrating the possibilities that telemedicine offered during the COVID-19 pandemic.

Conclusion:

An interdisciplinary approach can be performed for future follow ups on patients as various advantages were found by the patient and by the clinicians themselves.

Three-Dimensional Classification of Lower Third Molars and Their Relationship to the Mandibular Canal

PURPOSE

To develop a novel classification making full use of radiographic three-dimensional (3D) information to describe the position, geometric configuration of a mandibular third molar (M3M) and its spatial relation to neighboring structures such as the mandibular canal (MC). The classification presented in this study helps to establish a common language and serves as a framework for further studies, for example, on 3D parameters influencing prognosis of the M3M and level of difficulty associated with its removal.

MATERIAL AND METHODS

A total of 8 parameters were included in the classification including position, the cranio-caudal height, the number of roots of the M3M as well as its spatial relationship to the MC, its course, its deformation, and distance to the M3M. The classification was retrospectively applied to a sample of 483 patients and these data were statistically evaluated.

RESULTS

The most commonly observed categories were the (+) vertical position (39.8%); the cranio-caudal height A (38.7%); 2 roots (83.2%); and the spatial relationship no contact caudal (37.5%). Contact between the M3M and inferior alveolar nerve was observed in 58% of all cases. A deformation of the MC was found in 81% of cases.

CONCLUSIONS

Our novel classification aims to provide a more holistic description of parameters defining 3D M3M position, as well as its spatial relation to relevant neighboring structures. It creates a uniform terminology that can be applied in practice by surgeons and radiologists, and also serves as a foundation for further research projects, such that results from similarly designed studies could be compared.

CBCT Radiological Features as Predictors of Nerve Injuries in Third Molar Extractions: Multicenter Prospective Study on a Northeastern Italian Population

Background: Neurological alterations are one of the main complications occurring after the third molar extractions. The aim of this prospective multicenter cohort study was to find out Cone Beam Computed Tomography (CBCT) features and distribution of neurological complications in patients undergoing lower third molar surgery and to determine the radiological and patient-related factors that could be correlated to the occurrence of inferior alveolar and lingual nerves injury. Material and Methods: 378 patients who underwent lower third molar extraction from March 2018 to March 2019 were included. Clinical and radiological data were collected. CBCT features were recorded following Maglione et al. classification. Symptoms and characteristics of patients who experienced neurological alterations were evaluated. Results: 193 patients needed a second-level radiological exam (CBCT). In these patients, the most common feature was Maglione class 3: a higher frequency of apical or buccal mandibular canals in direct contact with the tooth was observed. 3.17% of the patients developed a neurological complication. Maglione class 4, increased age, and operative time were all positively correlated with neurological alterations. Conclusions: while the buccal or apical position of the mandibular canal was the more common findings, the lingual position was found to have a higher correlation with a negative outcome. Age and operative time were also found to be risk factors for developing nerve injury in the considered population.

Anatomical Risk Factors of Inferior Alveolar Nerve Injury Association with Surgical Extraction of Mandibular Third Molar in Korean Population

The purpose of this study was to analyze the incidence and risk factors of possible inferior alveolar nerve (IAN) injury after extraction of the mandibular third molars. A total of 6182 patients were examined for 10,310 mandibular third molar teeth. Panoramic radiography and patients’ medical records were used to analyze age, gender, and impaction pattern of the mandibular third molar. Cone beam computed tomography (CBCT) was used to investigate the detailed pathway of the inferior alveolar nerve and evaluated the presence of symptoms of nerve damage after tooth extraction. In CBCT, 6283 cases (61%) of the inferior alveolar nerve were actually in contact with the root of the mandibular third molar. The correlation with the panoramic signs of root darkening (p < 0.001), root deflection (p < 0.001), interruption of the IAN (p < 0.001), diversion of the IAN (p < 0.001), and narrowing of the IAN (p < 0.001) had statistical significance. Of the 4708 patients who underwent surgical extraction, 31 (0.658%) complained of nerve damage. Among them, 30 patients (0.637%) complained of symptoms of inferior alveolar nerve damage, and 1 patient (0.02%) complained of symptoms of lingual nerve damage. There was a significant correlation with IAN injury in cases where the roots became dark at the IAN area (p = 0.018) and there was diversion of the IAN at the root area (p = 0.041). When the narrowing of the IAN and the lingual driving pathway of the inferior alveolar nerve appeared simultaneously in CBCT, the risk of IAN injury was high.

Is MRI a viable alternative to CT/CBCT to identify the course of the inferior alveolar nerve in relation to the roots of the third molars?

Objectives

To assess the reliability of judging the spatial relation between the inferior alveolar nerve (IAN) and mandibular third molar (MTM) based on MRI or CT/CBCT images.

Methods

Altogether, CT/CBCT and MRI images of 87 MTMs were examined twice by 3 examiners with different degrees of experience. The course of the IAN in relation to the MTM, the presence/absence of a direct contact between IAN and MTM, and the presence of accessory IAN were determined.

Results

The IAN was in > 40% of the cases judged as inferior, while an interradicular position was diagnosed in < 5% of the cases. The overall agreement was good (κ = 0.72) and any disagreement between the imaging modalities was primarily among the adjacent regions, i.e., buccal/lingual/interradicular vs. inferior. CT/CBCT judgements presented a very good agreement for the inter- and intrarater comparison (κ > 0.80), while MRI judgements showed a slightly lower, but good agreement (κ = 0.74). A direct contact between IAN and MTM was diagnosed in about 65%, but in almost 20% a disagreement between the judgements based on MRI and CT/CBCT was present resulting in a moderate overall agreement (κ = 0.60). The agreement between the judgements based on MRI and CT/CBCT appeared independent of the examiner’s experience and accessory IAN were described in 10 cases in MRI compared to 3 cases in CT/CBCT images.

Conclusions

A good inter- and intrarater agreement has been observed for the assessment of the spatial relation between the IAN and MTM based on MRI images. Further, MRI images might provide advantages in the detection of accessory IAN compared to CT/CBCT.

Clinical relevance

MRI appears as viable alternative to CT/CBCT for preoperative assessment of the IAN in relation to the MTM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-020-03716-4.

Reliability of Cone Beam Computed Tomography in Comparison with Panoramic Radiography to Predict the Anatomical Relationship of Inferior Alveolar Nerve with Mandibular Third Molar: A Radiological and Clinical Study

Objectives:

The purpose of the study was to assess the precision of cone beam computed tomography (CBCT) in comparison with panoramic radiography in determining the anatomical relationship of inferior alveolar nerve (IAN) with the impacted mandibular third molar.

Materials and Methods:

Twenty patients diagnosed with the following panoramic radiographic markers: darkening of the root, interruption of white line of mandibular canal, diversion of mandibular canal, and narrowing of the roots suggesting a close relationship of roots with the mandibular canal were selected and underwent an additional CBCT to assess the proximity of IAN to mandibular third molar roots. All patients were assessed for loss of sensation or neurosensory deficit in the chin and lower lip during postoperative period by objective and subjective methods.

Results:

Twenty patients with an average age of 25.4 years (21–39 years) with 21 impacted mandibular third molars were included in this sample. It was found that after the removal of impacted third molars, IAN was not visible in any of the cases and postoperative objective and subjective neurosensory tests showed no signs of neurosensory disturbances.

Conclusion:

The study found that CBCT had limited usefulness in neurovascular bundle exposure prediction, prior to surgical removal of impacted mandibular third molars. The accuracy of radiographic markers in conventional panoramic radiography to predict neurovascular exposure was also limited.

Evaluation of Mandibular Third Molar Region in a Turkish Population Using Cone-Beam Computed Tomography

OBJECTIVES

To evaluate impacted mandibular third molar tooth region and obtain linear measurements using CBCT images and to assess the relationship between the impacted third molar and the mandibular canal.

METHODS

CBCT scans of 351 patients (208 females, 143 males) were assessed. Age, gender, and impaction site were recorded for each patient. The relationship of third molars with the vertical axis of second molars, 2nd molar resorption and the relationship between third molar apices and the mandibular canal were assessed. In addition, the distance between ramus and second molar, mesiodistal width of the third molar, the angle between third molar and second molar, and width of the third molar capsule were measured. Binary Logistic Regression, Chi-Square Test, and General Linear Model were used for statistical analysis.

RESULTS

The highest percentage of impaction was found for mesioangular followed by transversal and vertical. The transversal impacted third molars revealed a significant association with adjacent second molar root resorption (p<0.001). There was a statistical significance between the second molar resorption and distance between ramus and second molar (p<0.001). The mesioangular impacted third molars revealed significant relation with the mandibular canal (p<0.05). The most frequent variation found was the dental canal followed by the retromolar canal. In general, higher measurement values were obtained for men when compared to women (p<0.05).

CONCLUSION

CBCT assessment of the third molar region provided useful information regarding impacted mandibular third molar surgery operations.

Incidence of Pre-Existing Lingual Cortex Perforation Before Removal of Mandibular Third Molars

PURPOSE

The objective of this study was to determine the relationship between the mandibular third molar tooth (Md3) and the adjacent lingual cortical bone and determine the incidence of lingual cortex perforation by Md3s.

PATIENTS AND METHODS

This retrospective study was designed and implemented from 100 cone-beam computed tomographic scans (CBCTs) of patients with age ranging from 18 to 65 years old. The primary outcome was to assess the incidence of mandibular third molars (Md3s) with existing lingual cortex perforation by their roots. Perforation was assessed at the level of root apex and the most lingual portion on the apical half of the root. Other outcome variables included average thickness of covering lingual bone in the nonperforation group, lingual cortex morphology, impaction, and demographics. Descriptive statistics were computed.

RESULTS

More than half the radiographs showed lingual cortex perforation at the level of root apex and most lingual portion on the apical one half of the root (51.2% and 52.8%, respectively). The average thickness of the covering lingual bone was 1.25 mm around the root apex and 0.93 mm around the most lingual portion on the apical half of the root. The most common lingual cortex morphology was the undercut shape. There was statistically significant association between the presence of Md3 impaction and perforation at both root levels [(P value < .001, Effect size = 0.378) and (P value < .001, Effect size = 0.445)].

CONCLUSIONS

Perforation of the lingual cortex by Md3s, whether erupted or impacted, was found in >50% of patients as determined by a preoperative CBCT scan. Therefore, the finding of lingual cortex perforation after removal of Md3s is likely to be evidence of a pre-existing condition rather than a result of surgery.

Effect of CBCT dose reduction on the mandibular canal visibility: ex vivo comparative study

OBJECTIVES

To compare the difference in mandibular canal (MC) visibility using three different cone beam computed tomography (CBCT) acquisition protocols: high resolution (HR), standard resolution (ST) and Quick scan+ (QS+).

METHODS

Twenty-five human dry mandibles were scanned by one CBCT machine; i-CAT FLX (Imaging Sciences International, Hatfield, PA, USA), using three different acquisition protocols: high-resolution (HR), standard (ST) and Quick scan+ (QS+). DICOM data were transferred to a third party software Ondemand 3D (Cybermed Co., Seoul, Korea). The fusion module was used to superimpose images derived from different acquisition protocols to standardize the areas to compare the MC visibility. Comparison was performed at nine selected cross sections extending from an area distal to the third molar posteriorly to the first premolar anteriorly. Two expert radiologists evaluated the degree of MC visibility using five-scale scoring system.

RESULTS

There was a statistically significant difference between the three acquisition protocols (HR, ST, QS+) at all investigated areas regardless of dentition status (p value < 0.001-0.034) except at the MR1M area where there was no statistically significant difference (p value = 0.094). HR protocol showed the highest prevalence of fully and partially corticated MC at almost all investigated areas while QS+ protocol showed the highest prevalence of invisible MC and clear and unclear non-corticated MC at almost all investigated areas.

CONCLUSIONS

QS+ protocol of i-CAT FLX CBCT machine is a recommended low-dose CBCT acquisition protocol for MC visibility at dentulous posterior mandibular regions while ST protocol is recommended at edentulous areas.

Assessing the Prevalence and Morphological Characteristics of Bifid Mandibular Canal Using Cone-Beam Computed Tomography - A Retrospective Cross-Sectional Study

Objectives:

To evaluate the prevalence, location and configuration of bifid mandibular canals so as to avoid injury to the nerve and inadequate anesthesia during surgical procedures.

Materials and Methods:

CBCT scan of 203 patients (125 males and 78 females) was evaluated for the presence and the type of the bifid mandibular canal. They were classified according to Nortje et al. The prevalence rates were determined according to gender, location, and type of bifid mandibular canal. Statistical analysis was performed using IBM SPSS software version 24.

Results:

The prevalence rate of bifid mandibular canals was found to be 10.3% with 12.8% in males and 6.4% in females. The Chi-square test reveals there is a statistically significant difference between the different locations of bifid mandibular canals and most of the canals were present on the right side. The most frequent type of bifid mandibular canal observed was type II dental canal (38.1%), followed by type III forward canal (28.6%), type I retromolar canal (14.3%), and type IV buccolingual canal (14.3%).

Conclusion:

CBCT is suggested for a detailed evaluation and identification of bifid mandibular canals before any surgical procedures to avoid post-operative complications.

CBCT does not reduce neurosensory disturbances after third molar removal compared to panoramic radiography: a systematic review and meta-analysis

OBJECTIVES

The current dentistry scenario is showing an increase in the availability of cone-beam computed tomography (CBCT) in dental offices. Oral surgeons are using three-dimensional information as an additional tool to assess preoperative data for lower third molar (LTM) removal in moderate and high-risk cases of inferior alveolar nerve (IAN) injury diagnosed through the panoramic radiography (PR). The aim of this study is to identify whether CBCT examination reduces neurosensoric disturbances (ND) following the removal of the LTM when compared to PR.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, Science Direct, and Scopus electronic databases were searched for studies published up to February 2019. The gray literature was also searched including papers that eventually met the eligibility criteria. Meta-analysis was performed using the comprehensive meta-analysis software, p < 0.05 considered significant.

RESULTS

Among the search, 6 studies met all eligibility criteria. There was no statistically significant difference between the two groups (PR and CBCT) in all six studies regarding reducing ND (95%. Confidence interval, 0,788-1734; heterogeneity: Q = 10,361; I² = 22.788%).

CONCLUSIONS

CBCT was not superior to PR in avoiding ND. However, further studies are necessary with standardized parameters for a better comparability between variables in the studies.

CLINICAL RELEVANCE

To better understand the CBCT clinical applicability in LTM removal to avoid unnecessary extra radiation when compared to PR to the patient and to improve patient's prognosis.

Panoramic versus CBCT used to reduce inferior alveolar nerve paresthesia after third molar extractions: a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review was to verify whether CBCT in comparison with panoramic radiography reduced the cases of temporary paresthesias of the inferior alveolar nerve (IAN) associated with third molar extractions.

METHODS

The literature search included five databases (PubMed, Scopus, Web of Science, Cochrane, SciELO), in addition to gray literature and hand search of reference list of included studies. Two reviewers independently screened titles/abstracts, and full texts according to eligibility criteria, extracted data and evaluated risk of bias through Revised Cochrane Risk of Bias Tool for Randomized Trials (RoB 2.0). Data were meta-analyzed by comparing CBCT versus panoramic radiographs for number of events (temporary paresthesia after third molar surgery). Fixed effect model was used for non-significant heterogeneity; relative risk (RR) and 95% CI were calculated. The certainty of evidence was evaluated by Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

Four randomized controlled trials (RCTs) were included in meta-analysis, and for the majority of domains they presented low risk of bias. RR was 1.23 (95% IC: 0.75-2.02; I²: 0%; p = 0.43) favouring panoramic radiography, but without significant effect, and with moderate certainty of evidence.

CONCLUSIONS

We concluded that both interventions had a similar ability to reduce temporary paresthesia of the IAN after third molar surgery with moderate certainty of evidence.

Correlation of panoramic high-risk markers with the cone beam CT findings in the preoperative assessment of the mandibular third molars

Background/purpose

Preoperative radiographic examination of mandibular third molars (MTM) is essential to prevent inferior alveolar nerve (IAN) injury. The aim of this study was to assess the panoramic radiography (PAN) signs considered as indicators of increased risk of IAN injury and to correlate them with the cone beam CT (CBCT) findings.

Materials and methods

58 patients who had MTMs extraction between January 2012 and January 2018. OPG were evaluated for the following signs: interruption of the roof of the canal, root darkening, roots deflection and narrowing, canal deviation, superimposition between the MTM roots and mandibular canal. Loss of canal cortication, root grooving, thinning and perforation of lingual cortex were assessed in CBCT images. Chi-square test and multivariate logistic regression tests were used to test the relationship between PAN signs and CBCT findings.

Results

A total of 79 MTMs were examined. Loss of canal cortication in CBCT was seen in 22 (27.8%) of the cases. Root darkening in PAN images was the most frequent radiographic sign. Canal deviation and interruption of white line in PAN demonstrated a statistically significant correlation with the loss of canal cortication between the MTM and the mandibular canal on CBCT images (p = 0.004 and p = 0.012, respectively). No statistically significant association was observed for the other PAN signs and CBCT findings.

Conclusion

Canal deviation and interruption of white lines were associated with loss of canal cortication on CBCT, indicating a direct contact between the roots and the mandibular canal which required a further assessment prior to the extraction.

Diversion of the mandibular canal: Is it the best predictor of inferior alveolar nerve damage during mandibular third molar surgery on panoramic radiographs?

Purpose

The aim of this study was to evaluate the relationship between the mandibular canal and impacted mandibular third molars using cone-beam computed tomography (CBCT) and to compare the CBCT findings with signs on panoramic radiographs (PRs).

Materials and Methods

This retrospective study consisted of 200 mandibular third molars from 200 patients who showed a close relationship between the mandibular canal and impacted third molars on PRs and were referred for a CBCT examination of the position of the mandibular canal. The sample consisted of 124 females and 76 males, with ages ranging from 18 to 47 years (mean, 25.75±6.15 years). PRs were evaluated for interruption of the mandibular canal wall, darkening of the roots, diversion of the mandibular canal, and narrowing of the mandibular canal. Correlations between the PR and CBCT findings were statistically analyzed.

Results

In total, 146 cases (73%) showed an absence of canal cortication between the mandibular canal and impacted third molar on CBCT images. A statistically significant relationship was found between CBCT and PR findings (P<0.05). The absence of canal cortication on CBCT images was most frequently accompanied by the PR sign of diversion of the mandibular canal (96%) and least frequently by interruption of the mandibular canal wall (65%).

Conclusion

CBCT examinations are highly recommended when diversion of the mandibular canal is observed on PR images to reduce the risk of mandibular nerve injury, and this sign appears to be more relevant than other PR signs.

Cone beam CT imaging of the mandibular third molar: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology (EADMFR)

OBJECTIVES

Lack of evidence on the use of CBCT for management of mandibular third molars in Radiation Protection guideline no. 172 of the European Commission made the European Academy of DentoMaxilloFacial Radiology (EADMFR) decide to update the recommendations of the guideline.

METHODS AND MATERIALS

A literature search was performed addressing the following questions: (1) does CBCT change the treatment of the patient?; (2) does CBCT reduce the number of post-operative sensory disturbances of the inferior alveolar nerve?; and (3) can CBCT predict the risk for a post-operative sensory disturbance of the inferior alveolar nerve?

RESULTS: 

Since the European Commission published the guideline in 2012 several high-evidence studies on the use of CBCT before removal of mandibular third molars have been conducted including five randomized controlled clinical trials and one meta-analysis. Present literature allows to propose recommendations with highest level of evidence.

CONCLUSION

New and up-to-date evidence-based recommendations advocate that CBCT imaging of the mandibular third molar should not be applied as a routine method before removal of mandibular third molars and therefore, CBCT imaging should only be applied when the surgeon has a very specific clinical question in an individual patient case that cannot be answered by conventional (panoramic and/or intraoral) imaging.

Preoperative Anatomic Evaluation of the Relationship Between Inferior Alveolar Nerve Canal and Impacted Mandibular Third Molar in a Population of Bhubaneswar, Odisha, Using CBCT: A Hospital-Based Study

Purpose

To evaluate the correlation between the position of inferior alveolar nerve canal and the angulation of impacted mandibular third molars using cone beam computed tomography (CBCT) in a hospital-based study in the state of Odisha, India.

Materials and Methodology

Three hundred cases of impacted third molars in 200 patients (154 males; 46 females) were included in the study, for whom an initial periapical or panoramic radiograph had revealed that the mandibular canal and the lower third molars were in close proximity. A CBCT scan of each patient was carried out to assess how the canal position influenced the class and position of impaction, angulation of impaction and bone contact.

Results

Class II position B impactions were found in 78.37% cases where the position of ID canal was approximate to the lingual plate and inferior to third molar (73.75%). The results were statistically significant (p = 0.00). 80% of the ID canals showed bone contact. Of these 73.75% ID canals showed lingual bone contact. Mesioangular impactions were most common in mandible and significantly associated with lingual and inferior positioning of the canal.

Conclusions

The study mostly exhibited patients having mesioangular class II position B third molar impactions of the mandible. The position of the canal has a significant influence on the type of impaction and the bone contact.

Orthopantomography and Cone-Beam Computed Tomography for the Relation of Inferior Alveolar Nerve to the Impacted Mandibular Third Molars

Context:

Relation of inferior alveolar nerve to the impacted mandibular third molars (IMTMs).

Aims:

The aim of this study was to assess the reliability of seven specific radiographic signs of mandibular third molar root that are observed on orthopantomography (OPG) and to predict the proximity and the absence of corticalization between the mandibular canal and IMTM root on cone-beam computed tomography (CBCT) images.

Settings and Design:

The present study was conducted in the Department of Oral and Maxillofacial Surgery, Raja Rajeswari Dental College and Hospital.

Subjects and Methods:

Data set of 30 panoramic images was retrieved between the year of 2015 and 2016 indicated for extraction of lower third molars. The sample consisted of 30 individuals, who underwent preoperative radiographic evaluation before the extraction of impacted mandibular third molars (IMTM). Patients aged above 18 years with any of the seven specific signs observed on the panoramic radiograph which includes darkening, deflection, narrowing of roots, bifid root apex, diversion, narrowing of canal and interruption in the white line of the canal were included in the study. If any of the above mentioned seven specific sign were present, the patient was subjected to CBCT. On the CBCT images, the canal was traced in three planes. The acquired images were assessed for the presence or absence of corticalization.

Statistical Analysis Used:

Descriptive and inferential statistical analyses were used. Proportions were compared using the Chi-square test and Student's t-test.

Results:

Among the 4 subjects, diagnosed with an absence of corticalization, patients with isolated darkening of root P = 0.001 and patients with isolated interruption in white line P = 0.69. Patients with darkening of root in association with interruption in white lines on OPG showed the absence of corticalization on CBCT findings P = 0.001, respectively.

Conclusions:

This study showed the poor reliability of radiographic signs seen on OPG on predicting the proximity of third mandibular root with mandibular canal related to CBCT finding. Four were diagnosed with the absence of corticalization in CBCT findings.

Do we need CBCTs for sufficient diagnostics?-dentist-related factors

Background

The aim of this study was to assess the diagnostic accuracy of various dentoalveolar pathologies based on panoramic radiography (OPG), cone beam computed tomography (CBCT) and printed 3D models in consecutive order; and to evaluate the impact of specialisation of residents in oral surgery (OS) versus residents in orthodontics (ORTH).

Methods

Fourteen residents were recruited to evaluate nine selected cases with different dentoalveolar pathologies. The residents were given for each case an OPG, a CBCT and a printed 3D model. For each case and imaging modality, the residents were asked several questions relating to (i) diagnosis, and (ii) the request for consecutive imaging in order to enable treatment. Further, aspects like impact of specialisation (OS versus ORTH), gender and years of experience were analysed.

Results

In this study, diagnostic accuracy (i) improved for OS from OPG to CBCT (OPG 66.3%, CBCT 83.4%) and likewise for ORTH (OPG 63.7%, CBCT 78.0%). 3D models generally did not seem more useful than CBCTs. For treatment planning (ii), residents in orthodontics considered OPGs significantly more often as sufficient compared to residents in oral surgery (OR 6.3, p < 0.001). Further, the odds to request a CBCT after OPG for treatment planning is influenced by dentist-related factors: female dentists (OR 3.8) or residents with limited professional experience as dentists (OR 3.0) asked more frequently for a CBCT.

Conclusions

Overall diagnostic accuracy is decent with OPG and can be improved with CBCT. Specialisation seems to have a moderate impact on diagnostic accuracy, but influences whether a CBCT was requested for treatment planning. Based on these findings, future studies shall analyse the diagnostic accuracy of specific pathologies in higher number in order to substantiate the present findings with regard to specific pathologies.

Impact of voxel size and scan time on the accuracy of three-dimensional radiological imaging data from cone-beam computed tomography

PURPOSE

Three-dimensional (3D) radiological imaging plays an important role in surgical planning used in modern dentistry. The aim of this study was to optimize imaging parameters with a special focus on voxel size and scan time.

MATERIAL AND METHODS

A virtual 3D master model of a macerated human skull was generated using an industrial optical noncontact white light scanner. The skull was X-rayed with cone-beam computed tomography that was applied using different settings for voxel size and acquisition time (voxel edge length of 0.3 mm, scan times 4.8 s and 8.9 s; voxel edge length of 0.2 mm, scan times 14.7 s and 26.9 s). The scan was repeated 10 times at each setting. The CBCT scans were converted into 3D virtual models (actual value), which were superimposed with the 3D master model (reference value) to detect absolute differences.

RESULTS

The mean value of deviation increased with increasing voxel size and decreasing scan time. For a voxel edge length of 0.3 mm, the mean values of deviation were 0.33 mm and 0.22 mm with scan times of 4.8 s and 8.9 s, respectively. For a voxel edge length of 0.2 mm, the mean deviations were 0.16 mm and 0.14 mm with scan times of 14.7 s and 26.9 s, respectively.

CONCLUSIONS

When using small voxel sizes, the scan time does not have a significant impact on image accuracy and therefore the scan time can be shortened. However, for larger voxel sizes, shorter scan times can lead to increased inaccuracy.