J Oral Maxillofac Surg

66:2308-2313, 2008

Clinical Assessment of the Relationship

Between the Third Molar and the Inferior
Alveolar Canal Using Panoramic Images
and Computed Tomography
Kenji Nakamori, DDS, PhD,* Kumiko Fujiwara, DDS, PhD,†
Akihiro Miyazaki, DDS, PhD,‡ Kei Tomihara, DDS, PhD,§
Manabu Tsuji, DDS,¶ Mitsuyoshi Nakai, DDS,#
Yoshitaka Michifuri, DDS,** Rina Suzuki, DDS,††
Kiyoto Komai, DDS,‡‡ Makoto Shimanishi, DDS,§§ and
Hiroyoshi Hiratsuka, DDS, PhD¶¶
Purpose: To predict the relationship between lower third molars and the inferior alveolar canal (IAC)
from panoramic radiographs, and to establish criteria for using computed tomography (CT).
Materials and Methods: A retrospective cohort study was performed involving 443 patients (695
teeth). Predictor variables were the distance between the third molar and the IAC, and findings according
to the Rood’s criteria. Outcome variables were the absence of cortication between the third molar and the IAC
on the CT image, and injury of the inferior alveolar nerve (IAN). Statistical analysis was performed to
assess the relationship between predictor and outcome variables.
Results: All patients had preoperative panoramic radiographs, and 71 patients (119 teeth) also had CT
images. On CT examination, 48 teeth (40.3%) showed absence of cortication. Injury of the IAN was
reported in 7 cases (1.0%), 5 of which exhibited absence of cortication; the remaining 2 did not have CT
scans. Five of the 48 cases showing absence of cortication exhibited IAN injury, and none of the cases
with cortication exhibited IAN injury. On the panoramic images, the following signs were strongly
correlated with absence of cortication: a superimposed relationship between the third molar and the
IAC; darkness of the root; and diversion and narrowing of the IAC.
Conclusion: Presence of Rood’s criteria was a predictor for a contact relationship between the third
molar and the IAC, and an indication for CT examination. However, a superimposed relationship and the
absence of Rood’s criteria did not necessarily signify a separate relationship between third molar and the
IAC.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:2308-2313, 2008

*Instructor, Department of Oral Surgery, Sapporo Medical Uni-
versity, Sapporo, Japan.
†Assistant Professor, Division of Oral and Maxillofacial Congeni-
tal Anomaly, Aichi-Gakuin University Hospital, Aichi, Japan.
‡Assistant Professor, Department of Oral Surgery, Sapporo Med-
ical University, Sapporo, Japan.
§Clinical Fellow, Department of Oral Surgery, Sapporo Medical
University, Sapporo, Japan.
¶Instructor, Department of Oral Surgery, Sapporo Medical Uni-
versity, Sapporo, Japan.
#Graduate Student, Department of Oral Surgery, Sapporo Medi-
cal University, Sapporo, Japan.
**Graduate Student, Department of Oral Surgery, Sapporo Medi-
cal University, Sapporo, Japan.
††Clinical Fellow, Department of Oral Surgery, Sapporo Medical
University, Sapporo, Japan.
‡‡Clinical Fellow, Department of Oral Surgery, Sapporo Medical
University, Sapporo, Japan.
§§Graduate Student, Department of Oral Surgery, Sapporo Med-
ical University, Sapporo, Japan.
¶¶Professor and Chairman, Department of Oral Surgery, Sapporo
Medical University, Sapporo, Japan.
Address correspondence and reprint requests to Dr Nakamori: Depart-
ment of Oral Surgery, Sapporo Medical University, South-1, West-16 Chuo-
ku, Sapporo 060-8543, Japan; e-mail: nakamori@sapmed.ac.jp
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6611-0018$34.00/0
doi:10.1016/j.joms.2008.06.042

2308
NAKAMORI ET AL
Several complications of lower third molar surgery
have been reported, including alveolar osteitis, infec-
tion, and lingual nerve injury.1,2 The incidence of
paresthesia of the inferior alveolar nerve (IAN) is
reported to be 0.5% to 8%. Paresthesia of the IAN has
been linked to factors such as age,1,3 gender,4 type of
anesthesia used,5 and the experience of the surgeon.6
Many studies have investigated the anatomic rela-
tionship between the lower third molar and the
inferior alveolar canal (IAC).3,7-10 Panoramic radiog-
raphy is frequently used in treatment planning for
third molar surgery. Therefore, there is a need for a
simple and reliable method for predicting paresthe-
sia of the IAN by evaluating panoramic radiographs.
Several studies have proposed risk factors for IAN
injury based on findings from panoramic images;
however, because of the low incidence of IAN
injury, reliable predictive factors have not yet been
established.
Exposure of the neurovascular bundle during third
molar surgery may cause mechanical damage to the
nerve, and the incidence of IAN injury is reported to
be approximately 20%.6 Some recent studies have
evaluated the relationship of the third molar to the
IAC using computed tomography (CT).4,8,11-13 Mae-
gawa et al8 reported that the absence of cortication
around IAC was closely related to exposure of IAN.
There is no doubting the usefulness of CT to assess
the relationship between teeth and the IAC; however,
it is not necessary for all cases of impacted mandibular
third molars to undergo CT examination.
The purposes of this study were: 1) to establish a
method of predicting contact relationships between
teeth and the IAC using a panoramic image alone; 2)
to assess the usefulness of CT to predict an IAN injury;
and 3) to set criteria for cases requiring CT examina-
tion.
Materials and Methods
STUDY DESIGN/SAMPLE
To address the research purpose, the investigators
designed and implemented a retrospective cohort
study. The study population was composed of all
patients presenting to the Department of Oral Surgery
at Sapporo Medical University Hospital (Sapporo,
Hokkaido, Japan) for evaluation and management of
lower third molars between April 2005 and March
2007. To be included in this study sample, patients
had to provide preoperative and postoperative data
about their third molar surgery. Patients were ex-
cluded as study subjects if they had another impacted
tooth to be extracted (for example, an impacted premo-
lar), if they had a lesion (such as a tumor or cyst) around
the third molar, or if they were lost to follow-up.
2309
STUDY VARIABLES
The primary predictor variable was the distance
between the tooth and the IAC as observed on pan-
oramic radiographs. The secondary predictor variable
was the relationship of the tooth to the IAC according
to the criteria established by Rood and Shehab.14
Because many studies have supported the usefulness
of Rood’s criteria,3,7,9-11,13,15,16 in the current study
we used 3 tooth-related findings (darkness of the root,
narrowing of the root, and deflection of the root) and
3 canal-related findings (narrowing of the canal, diver-
sion of the canal, and interruption of the white line).
The first outcome variable was presence or absence
of cortication between the tooth and the IAC using
restructured coronal or cross-sectional CT images.
Absence of cortication was defined as loss of cortical
lining between the tooth and the IAC. The second
outcome variable was IAN injury as evidenced by
paresthesia of the lower lip. To assess the paresthesia,
touch-pressure thresholds were measured using a
Semmes-Weinstein monofilament (Sakai Medical Co
Ltd, Tokyo, Japan). Cases with loss of light touch
sensation (⬍ 2.44 filament marking) were recognized
as exhibiting paresthesia. In addition, age, gender,
tooth site, and position were recorded.
DATA COLLECTION METHODS
The distance between the tooth and the IAC was
measured with digital calipers by 2 examiners (K.N.
and K.F.) using the Picture Archiving and Communi-
cation System (SYNAPSE, Fujifilm Medical Co Ltd,
Tokyo, Japan). Each case was measured by each ex-
aminer 3 times, and the average value was recorded.
The inferior root apex or a portion of the crown was
used as a radiographic landmark. If the tooth land-
mark was inferior to the superior border of the IAC, a
negative value was recorded. Rood’s criteria were
evaluated on the panoramic image by 2 examiners
(K.N. and M.T.). When the assessments of the 2 ex-
aminers differed, a consensus was reached by discus-
sion. CT scanning was used to classify the relationship
between the tooth and the IAC (ie, the presence or
absence of cortication).8 Data for all study were col-
lected and entered into a spreadsheet.
SUMMARY OF OPERATIVE METHODS
Extraction of the third molars was performed under
general or local anesthesia by various surgeons (special-
ist oral surgeon, senior resident, and trainee). Alveolar
bone removal and tooth sectioning was performed if
necessary; however, the lingual split technique was not
undertaken.
DATA ANALYSES
Statistical analysis was performed using Stat View
software (Stat View for Windows Version 5; SAS In-
2310 CLINICAL ASSESSMENT OF THIRD MOLAR AND IAC

stitute Inc, Cary, NC). A ␹2 test and logistic regression Table 2. INCIDENCE OF EACH PANORAMIC FINDING
analysis were performed to assess the panoramic find-
ings and the absence of cortication. No. of Cases
Panoramic Findings (N ⫽ 695) %

Results Distance of tooth from IAC

Separate (⬎0.5 mm) 158 22.7
The subjects consisted of 196 males and 247 fe- Attached (⫺0.5 mm to 0.5 mm) 221 31.8
males (mean age, 31.4 years; range, 15 to 78 years). In Superimposed (⬍ ⫺0.5 mm) 316 45.5
Darkness of the root 19 2.7
all patients, a panoramic image was taken routinely
Deflection of the root 27 3.9
and used to assess the indications for third molar Narrowing of the root 4 0.6
surgery and to plan the treatment. Panoramic images Diversion of the canal 19 2.7
of 695 teeth were investigated with regard to tooth Narrowing of the canal 28 4.0
position (mesioangular, horizontal, vertical, distoan- Interruption of white line 65 9.4
gular, and buccolingual) (Table 1). Nakamori et al. Clinical Assessment of Third Molar and IAC.
Three groups were established based on the dis- J Oral Maxillofac Surg 2008.
tance of the tooth from the IAC: 158 (22.7%) of the
teeth were “separate” (more than 0.5 mm from the
criteria) and the presence or absence of cortication.
IAC), 221 (31.8%) were “attached” (between ⫺0.5
The distance from the IAC and the presence of 3
mm and 0.5 mm from the IAC), and 316 (45.5%) were
criteria (darkness of the root, diversion of the IAC,
“superimposed” (less than ⫺0.5 mm from the IAC).
and narrowing of the canal) were shown to be closely
According to Rood’s criteria,14 the following signs
related to the absence of cortication (␹2 test P ⫽
were observed on the panoramic radiographs: inter-
.0245, P ⫽ .0049, P ⫽ .0019, P ⫽ .0003, respectively).
ruption of the white line of the IAC: 65/695 (9.4%),
Based on these results, the subjects were divided into
narrowing of the canal; 28/695 (4.0%), deflection of
3 groups: the high risk group (exhibiting the criteria
the roots; 27/695 (3.9%), darkness of the roots; 19/
of darkness of the root, diversion of the IAC, and
695 (2.7%), diversion of the IAC; 19/695 (2.7%), and
narrowing of the roots; 4/695 (0.6%). There were no
cases exhibiting a “dark and bifid apex.” Table 2 lists
Table 3. RELATIONSHIP BETWEEN PANORAMIC
the distance of the teeth from the IAC and these signs. AND CT FINDINGS
When the third molar was assessed as having a
close relationship with the IAC on the panoramic Cortication
image, a CT image was taken to examine the anatomic Between Tooth
and IAC
relationship in further detail. Of the 695 teeth, 119
were evaluated by CT, after informed consent was Panoramic Findings Absence Presence ␹2 Test
obtained. Distance from IAC P ⫽ .0245
Of the 119 teeth examined by CT, 48 teeth (40.3%) Separate (n ⫽ 9) 0 9
showed absence of cortication between the tooth and Attached (n ⫽ 30) 11 19
the IAC. Table 3 shows the relationship between the Superimposed (n ⫽ 80) 37 43
Darkness of the root P ⫽ .049
panoramic findings (ie, distance from the IAC, Rood’s yes (n ⫽ 12) 8 4
no (n ⫽ 107) 40 67
Deflection of the root NS
Table 1. PATIENT AND THIRD MOLAR yes (n ⫽ 8) 5 3
CHARACTERISTICS no (n ⫽ 111) 43 68
Narrowing of the root NS
Age 15-78 (mean, 31.4) yes (n ⫽ 3) 3 0
Gender female, 247; male, 196 no (n ⫽ 116) 45 71
Site Diversion of the canal P ⫽ .0019
Right 337 yes (n ⫽ 14) 11 3
Left 358 no (n ⫽ 105) 37 68
Third molar position Narrowing of the canal P ⫽ .0003
Mesioangular 158 yes (n ⫽ 23) 17 6
Horizontal 366 no (n ⫽ 96) 31 65
Vertical 139 Interruption of white line NS
Distoangular 17 yes (n ⫽ 43) 21 22
Buccolingual 15 no (n ⫽ 76) 27 49
Abbreviation: NS, not significant. Abbreviation: NS, not significant.
Nakamori et al. Clinical Assessment of Third Molar and IAC. Nakamori et al. Clinical Assessment of Third Molar and IAC.
J Oral Maxillofac Surg 2008. J Oral Maxillofac Surg 2008.
NAKAMORI ET AL 2311

narrowing of the canal); the low risk group (exhibit-
ing the other 3 criteria; deflection of the root, narrow-
ing of the root, and/or interruption of white line); and
the no sign group (exhibiting none of Rood’s criteria).
These 3 groups were closely related to the absence of
cortication (␹2 test P ⬍ .0001) (Table 4).
Temporary paresthesia of the IAN was reported in
7 of the 695 teeth (1.0%), and no cases of permanent
paresthesia were reported. On panoramic photo-
graphs, the patients of paresthesia were observed in 2
of 93 cases (2.2%) in the high risk group, 2 of 121
cases (1.7%) in the low risk group, and 3 of 480 cases
(0.6%) in the no sign group. Six of the 7 patients with
paresthesia showed a superimposed relationship be-
tween the tooth and the IAC, and 1 case had an
attached relationship. Five out of the 7 cases exhib-
ited absence of cortication, while the remaining 2
cases did not undergo CT examination. Based on the
CT findings, the incidence of injury to the IAN was 5
of 48 (10.4%) in cases where cortication was absent,
and there were no reports of injury to the IAN in cases
where cortication was present (Table 5).
To assess the relationship between the radio-
graphic findings and the absence of cortication, mul-
tivariate analysis was performed using logistic regres-
sion analysis. The distance of the tooth from the IAC
and narrowing of the canal was significantly related to
the absence of cortication (P ⫽ .0023, P ⫽ .0014,
respectively) (Table 6).
FLOW CHART
The ␹2 and logistic regression analysis were used to
produce a flow chart for predicting the absence of
cortication between the tooth and the IAC (Fig 1).
When the distance between the tooth and the IAC
was more than 0.5 mm, absence of cortication be-
tween the tooth and the IAC did not occur. Absence
Table 4. RELATIONSHIP BETWEEN PANORAMIC
FINDINGS ACCORDING TO RISK GROUP BASED ON
ROOD’S CRITERIA AND ABSENCE OF CORTICATION
Table 5. RELATIONSHIP BETWEEN PANORAMIC OR
CT FINDINGS, AND INJURY OF IAN
Injury Incidence of
of IAN Injury of
Panoramic or CT Findings Yes No IAN (%)
Absence of cortication (n ⫽ 48) 5 43 (10.4)
Presence of cortication (n ⫽ 71) 0 71 –
Nakamori et al. Clinical Assessment of Third Molar and IAC.
J Oral Maxillofac Surg 2008.
of cortication between the tooth and the IAC oc-
curred in 11 of 30 cases (36.7%) where the tooth and
the IAC were attached (distance from the tooth to the
IAC between ⫺0.5 and 0.5 mm). When an attached
relationship was recognized, “narrowing of the canal”
became a powerful predictor for absence of cortica-
tion (10 of 13 or 76.9%). When the attached types
were divided into 2 groups with or without “narrow-
ing of the canal,” sensitivity and specificity were
90.9% and 85.0%, respectively. If the tooth and the
IAC were superimposed (distance from the tooth to
the IAC ⬍ ⫺0.5 mm), absence of cortication occurred
in 37 of 80 cases (46.3%). When 1 or more of Rood’s
criteria were present, the absence of cortication in-
creased to 29 of 55 cases (52.7%). When none of
Rood’s criteria were present, absence of cortication
occurred in 8 of 25 cases (32.0%), and the sensitivity
and specificity were 75.7% and 47.2%, respectively. In
teeth positioned mesioangularly or vertically, absence
of cortication occurred in 7 of 10 cases (70%); how-
ever, of the teeth positioned horizontally, only 1 tooth
was in a contact relationship with the IAC.
Discussion
The close anatomic relationship between the lower
third molar and the IAC may result in IAN injury during
third molar surgery. To prevent this complication, many
studies have proposed risk factors for IAN injury based

Cortication Between Table 6. MULTIVARIATE MODEL FOR PREDICTING

Tooth and IAC ABSENCE OF CORTICATION BETWEEN TOOTH AND
IAC BASED ON PANORAMIC FINDINGS
Panoramic Findings Absence Presence

High risk group (n ⫽ 38) 26 12 95% Confidence

Low risk group (n ⫽ 31) 13 18 Panoramic Findings Intervals P Value
No sign group (n ⫽ 50) 9 41
Distance of the tooth from IAC 1.186-2.192 .0023
NOTE. High risk group: exhibiting the criteria of darkness Darkness of the root 0.108-2.511 .4156
of the root, diversion of the canal, and/or narrowing of the Deflection of the root 0.179-6.563 .9301
canal. Low risk group: exhibiting the criteria of deflection of Narrowing of the root 0.020-4.034 .3818
the root, narrowing of the root, and/or interruption of white Diversion of the canal 0.060-1.344 .1122
line. No sign group: exhibiting none of Rood’s criteria. Narrowing of the canal 0.033-0.439 .0014
P ⬍ .0001 (␹2 test). Interruption of white line 0.216-1.350 .1876
Nakamori et al. Clinical Assessment of Third Molar and IAC. Nakamori et al. Clinical Assessment of Third Molar and IAC.
J Oral Maxillofac Surg 2008. J Oral Maxillofac Surg 2008.
2312 CLINICAL ASSESSMENT OF THIRD MOLAR AND IAC

FIGURE 1. When the distance between the tooth and the IAC was more than ⫺0.5 mm (separate relationship), absence of cortication
occurred infrequently. In cases with an attached relationship (distance between tooth and IAC of between ⫺0.5 and 0.5 mm), “narrowing
of the canal” was a powerful predictor for absence of cortication. In cases with a superimposed relationship (distance between the tooth and
the IAC less than ⫺0.5 mm), if 1 or more of Rood’s criteria were present, or if the tooth was positioned mesioangularly or vertically in the
absence of Rood’s criteria, there was a high risk of absence of cortication.
Nakamori et al. Clinical Assessment of Third Molar and IAC. J Oral Maxillofac Surg 2008.

on findings from panoramic images.9,10,14,16 Direct ex-
posure of the neurovascular bundle and/or a contact
relationship between the tooth and the IAN on CT
increases the incidence of injury to the IAN by ap-
proximately 20% to 30%.6,11 However, contact rela-
tionships on CT images are observed more frequently
than the occurrence of IAN injury. This study focuses
on 1) establishing a method of predicting contact
relationships between teeth and the IAC using a pan-
oramic image alone; 2) assessing the usefulness of CT
to predict IAN injury; and 3) setting criteria for cases
requiring CT examination.
Panoramic images allow the vertical and 2-dimen-
sional relationship between the tooth and the IAC to be
assessed. In this study, predictor variables were the
distance between the tooth and the IAC, and alteration
in the tooth and/or the IAC based on Rood’s criteria.
They were considered to be predictive of the proximity
of the tooth to the IAC on panoramic images.
Digital calipers can accurately discriminate dis-
tances of about 0.01 mm; however, human visual
acuity is accurate only to approximately 0.5 mm.17
Therefore, the distance of the tooth from the IAC was
categorized as separate (more than 0.5 mm), attached
NAKAMORI ET AL
(between ⫺0.5 and 0.5 mm) or superimposed (less
than ⫺0.5 mm). On the panoramic images of 695
teeth, 537 teeth (76%) were categorized as attached
or superimposed. There were 513 teeth that exhib-
ited none of Rood’s criteria. The most frequent find-
ing was “interruption of the white line;” however, the
incidence of this finding was only 9.4%. This result is
consistent with a study by Bell,7 who reported 206 of
300 touching or superimposed teeth, and found the
incidence of Rood’s criteria to be 0.5% to 23%. These
results suggest that cases classified as attached or
superimposed by observation of the panoramic image
have a low incidence of Rood’s criteria.
In this study, degree of distance of the tooth from
the IAC, and presence of Rood’s criteria were related
to absence of cortication between the tooth and the
IAC. Similar results were reported that Rood’s criteria
were closely related to the CT findings.8,12 Monaco et
al investigated the relationship between the presence
of Rood’s criteria and the CT findings, and found that
absence of cortication occurred in approximately
50% to 80% of cases.11 This is consistent with the
current study, where we found the incidence of ab-
sence of cortication was 48.8% to 100%. These find-
ings suggest that when Rood’s criteria are recognized,
the incidence of absence of cortication may be 50% or
more. However, a superimposed relationship and the
absence of Rood’s criteria did not necessarily signify a
separate relationship between the third molar and the
IAC.
We produced a flow chart involving the distance of
the tooth from the IAC and Rood’s criteria. Cases with
attached relationships based on the panoramic find-
ings and with “narrowing of the canal” in 10 of 13
cases, and without “narrowing of the canal” in 1 of 17
cases, also exhibited absence of cortication between
the tooth and the IAC. Mostly, in such cases, the IAC
was positioned under the tooth. It was considered
that “narrowing of the canal” directly reflected a con-
tact relationship between the tooth and the IAC. If the
tooth and the IAC seem to be superimposed, the
presence of Rood’s criteria is not a good predictor,
because of the low specificity. Absence of Rood’s
criteria does not necessarily mean a separate relation-
ship between the tooth and the IAC. According to our
results, if an attached relationship is recognized on
the panoramic image, the presence of “narrowing of
the canal” is considered to be a predictor for a contact
relationship and is an indication for CT examination.
When a superimposed relationship is observed on the
panoramic image, the presence of Rood’s criteria is
not a sufficient factor for predicting a contact rela-
tionship between the tooth and the IAC. Absence of
Rood’s criteria does not necessarily imply a separate
2313
relationship between the tooth and the IAC. In cases
with a superimposed relationship between the tooth
and the IAC, another finding is needed to predict a
contact relationship. Further comparative studies are
expected to reveal new reliable predictive findings
about contact relationships between teeth and the IAC.
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