SCIENTIFIC ARTICLE

Australian Dental Journal 2006;51:(1):64-68

Methods of determining the relationship of the mandibular

canal and third molars: a survey of Australian oral and
maxillofacial surgeons
B Koong,* MJ Pharoah, M Bulsara, M Tennant
Abstract
Background: Surgical extraction of third molars is
one of the most common oral and maxillofacial
surgical procedures performed and may have a
number of associated complications. One of these
complications is inferior alveolar nerve (IAN)
dysaesthesia or impairment of sensory perception
(including paraesthesia and/or anaesthesia). Previous
studies assume that most clinicians use various
combinations of nine radiologic criteria on
panoramic radiographs as indicators of the
relationship and, therefore, predictors of the risk of
postoperative dysaesthesia. Our study assessed both
the current radiologic modalities and assessment
criteria used by Australian oral and maxillofacial
surgeons when determining the proximity of
mandibular canal to third molars.
Methods: A survey of all surgeon members of the
Australian and New Zealand Association of Oral
and Maxillofacial Surgeons (ANZOMS) practising
in Australia was undertaken.
Results: Of the 105 questionnaires sent to surgeons,
72 responses (68 per cent) were returned. All
surgeons reported using the panoramic radiograph
but only 25 per cent considered it sufficiently
accurate in determining the relationship between the
mandibular canal (MC) and the third molar root,
while 61 per cent of surgeons use CT for this
purpose but the average frequency of use was very
low (five per cent). This study also revealed that the
nine radiologic criteria on a panoramic radiograph
are used to varying extents by Australian surgeons.
Nearly all surgeons use change in MC direction
and MC narrowing to determine and close
relationship. Thirty-one per cent used superimposition of the MC and the root of the third
molar alone and 24 per cent used appearance of
contact of the root with the MC alone in the absence
of any other radiologic criteria to indicate close or
intimate relationship.
Conclusion: Further research is required to
determine the accuracy and observer agreement or
reliability of using the nine panoramic
characteristics, to determine this relationship and

*Private practice, Faculty of Medicine and Dentistry, The University

of Western Australia.
Faculty of Dentistry, The University of Toronto, Canada.
Population Health, The University of Western Australia.
The Centre for Rural and Remote Oral Health, The University of
Western Australia.
64

whether the presurgical determination of proximity

and position (buccal or lingual) of the canal utilizing
CT has any usefulness in determining the surgical
protocol or affect on postoperative morbidity.
Key words: OMF, third molars, mandibular canal, inferior
alveolar nerve.
Abbreviations and acronyms: ANZOMS = Australian and
New Zealand Association of Oral and Maxillofacial
Surgeons; CT = computed tomography; IAN = inferior
alveolar nerve; MC = mandibular canal.
(Accepted for publication 30 June 2005.)

INTRODUCTION
Surgical extraction of third molars is one of the most
common oral and maxillofacial surgical procedures
performed and may have a number of associated
complications.1-10 One of these complications is inferior
alveolar nerve dysaesthesia or impairment of sensory
perception
(including
paraesthesia
and/or
anaesthesia).7,11 Dysaesthesia is perceived by patients as
a significant impairment to their well-being particularly
coupled with the risk of permanency of effect.1,2,10-16
From a surgical perspective, the significant risk
associated with dysaesthesia is determined by the
approximation of the inferior alveolar nerve (IAN), or
radiographically the mandibular canal (MC), to the
roots of the third molar. A review of research of this
relationship reveals a significant anatomical
variation.13,17-19 Because of this high variation in
IAN/third molar relationship, a detailed pre-operative
radiographic assessment is required to identify both the
position (buccal, lingual or inferior) and approximation
of MC to third molar to minimize the risk of
postoperative dysaesthesia.20,21 Previous studies have
assumed that most clinicians use panoramic radiographs
with a series of radiologic criteria as an indicator of the
relationship and thus the risk of postoperative
dysaesthesia. A detailed review of the last 30 years of
research reveals a focus on nine common radiographic
criteria (Table 1).7,13,15,19,22-37 The current study assessed
both the radiologic modalities and assessment criteria
used by Australian oral and maxillofacial surgeons
when determining the proximity of MC to third molars.
Australian Dental Journal 2006;51:1.

Table 1. Common criteria used for assessment of the relationship between the inferior alveolar nerve and the
lower third molars. These criteria are distilled from the literature of the past 30 years7,13,15,19,22-37
1

Radiolucent band

Loss of mandibular border

Change in mandibular canal direction

Mandibular canal narrowing

5
6

Root narrowing
Root deviation

Bifid apex

8
9

Superimposed
Contact mandibular canal

Increased radiolucency (radiolucent band) of the root(s) of the mandibular third molar where
the mandibular canal crosses it.
Interruption of the radiopaque lines which represent the superior and inferior borders of the
mandibular canal where it crosses the root(s) of the third molar.
Significant change in the direction of the mandibular canal where it is superimposed on or is in
contact with the root(s) of the mandibular third molar
Narrowing of the mandibular canal where it is superimposed on or is in contact with the
root(s) of the mandibular third molar
Narrowing of the root(s) of the mandibular third molar where the mandibular canal crosses it
Abrupt deviation in form (dilaceration) of the root(s) of the mandibular third molar where it is
superimposed on or is in contact with the mandibular canal
Bifid and dark apex of the root(s) of the mandibular third molar where the mandibular canal
crosses it
Superimposition of the root(s) of the mandibular third molar and the mandibular canal
Root(s) of the mandibular third molar in contact with the superior border of the mandibular
canal

Frequency of use

METHODS
After approval from the Human Ethics Committee of
The University of Western Australia was obtained, a
survey of all surgeons practising in Australia who were
members of the Australian and New Zealand
Association of Oral and Maxillofacial Surgeons
(ANZOMS) was undertaken.
The questionnaire obtained information on the
following three components of assessing the
relationship between the mandibular canal (MC) and
the third molars.

The frequency of use for each modality was

determined by estimating the number of cases (for each
modality) investigated over the previous 12 months.
Radiological criteria
Participants were asked to record the radiologic
criteria they used in diagnosing the MC/third molar
relationship in each panoramic image. The nine
radiologic criteria as determined in the initial metaanalysis were provided together with the opportunity
to list additional criteria. In addition, participants who
used computed tomography (CT) were asked to select
the radiologic criteria used on the initial conventional
radiographs that indicated the need of CT imaging.
Data from each questionnaire were entered into a
spreadsheet (Microsoft Excel) and were analyzed using
Stata version 8.0.

Imaging modalities
A series of questions determined the types of imaging
modalities: panoramic, periapical, lateral oblique
radiographs, CT scan or others used in determining
the relationship between the MC and the third molars.
Each imaging modality was rated for providing
sufficient information or has some limitations in
determining the relationship between the MC and the
roots of third molars for the safe and effective removal
of these teeth. Respondents were also asked to report
any combinations of imaging modalities they
considered were useful in increasing the precision of
their diagnosis.

RESULTS
Of the 105 questionnaires sent to surgeons (and
followed-up four weeks later with a reminder), 72
responses (68 per cent) were received.

Table 2. Imaging modalities used by oral and maxillofacial surgeons

OMFs using this modality n (%)
Panoramic radiograph
Periapical radiograph
Computed tomography
Lateral oblique rad
Others

72
35
44
9
2

(100.0)
(48.61)
(61.11)
(12.50)
(2.78)

Frequency of use in the last year

Mean (%) standard error

Min %

Max %

97.271.27
5.740.57
5.241.31
1.280.18
10.000.83

10.00
0.25
0.02
0.00
5.00

100.00
20.00
70.00
5.00
15.00

Sufficient information %
25.00
11.43
75.00
0.00
50.00

(Notes: Surgeons using this modality The number and percentage of respondents (Australian surgeons) who use this modality for the purpose
of determining the relationship between the mandibular canal and the roots of the mandibular third molar. Frequency of use in the last year Of
those who use this modality, the percentage of the total number of cases treated in the last year where this particular imaging modality has been
used. Sufficient information Of those who use this modality, the percentage of surgeons who consider that this same modality provides
sufficient information in determining the precise relationship between the mandibular canal and the roots of the mandibular third molar for the
safe and effective removal of these teeth.)
Australian Dental Journal 2006;51:1.

65

Table 3. Modality combinations considered useful

Combinations useful
to OMFs (n=72)
CT scan and panoramic radiograph
CT scan and periapical radiograph
Panoramic rad and periapical rad
Other combinations

38
3
8
4

(53%)
(4%)
(11%)
(6%)

(Note: Combinations useful to surgeons The number and

percentage of surgeons who consider this particular combination of
imaging modality to be particularly useful for the purpose of
determining the relationship between the mandibular canal and the
roots of the mandibular third molar.)

Imaging modalities
All oral and maxillofacial surgeons have used
panoramic radiographs for the purpose of determining
the MC/third molar relationship and do so very
frequently (97 per cent of cases in the last 12 months)
(Table 2). Almost half (49 per cent) of the surgeons
surveyed have used the periapical radiograph for this
purpose but did not use it very frequently (six per cent
in the 12 months). CT scans were used by 61 per cent
of responders although only for five per cent (for a
range of 0.02 per cent to 70 per cent) of cases within
the last 12 months. The lateral oblique radiograph was
rarely (one per cent) used by only 13 per cent of
surgeons surveyed. Other imaging modalities were not
used to any significant extent. Of all the surgeons who
use the panoramic radiograph, only 25 per cent
consider that this image by itself provided sufficient
information in determining the precise MC/third molar
relationship for the safe and effective extractions (Table
1). In contrast, 75 per cent of surgeons who utilize CT
scans considered this imaging modality by itself would
provide sufficient information. Of the surgeons who
used the periapical radiograph, a few (11 per cent)
considered this projection by itself to provide sufficient
information. Of those who used the lateral oblique
radiograph, none considered this projection to provide
sufficient information. More than half (53 per cent) the

Table 4. Radiologic criteria considered by oral and

maxillofacial surgeons to indicate close/intimate
relationship
Indicator of close/intimate
relationship (n=72)
1. Radiolucent band
2. Loss of MC border
3. Change MC direction
4. MC narrowing
5. Root narrow
6. Root deviation
7. Bifid apex
8. Superimposed*
9. Contact MC*
Others

54
55
67
69
40
48
39
22
17
3

(75%)
(76%)
(93%)
(96%)
(56%)
(67%)
(54%)
(31%)
(24%)
(4%)

(*In the absence of the criteria 17 listed above.

Note: Criteria indicating close or intimate relationship The
number and percentage of surgeons who consider this radiologic
criteria on a panoramic image to indicate a close or intimate
relationship between the mandibular canal and the roots of the
mandibular third molar.)
66

Table 5. Radiologic criteria indicating need for CT

scan (n=44)
Indicator for CT scan
1. Radiolucent band
2. Loss of MC border
3. Change MC direction
4. MC narrowing
5. Root narrrow
6. Root deviation
7. Bifid apex
8. Superimposed
9. Contact MC
Others

10
14
17
25
16
14
11
2
3
5

(23%)
(32%)
(39%)
(57%)
(36%)
(32%)
(25%)
(5%)
(7%)
(11%)

(Note: Radiologic criteria indicating need for CT scan Of the

respondents who use CT scans, the number and percentage of
surgeons who consider this radiologic criteria on a panoramic image
to indicate a need for CT scan to determine the relationship between
the mandibular canal and the roots of the mandibular third molar.)

respondents considered the combination of CT scans

and the panoramic radiograph to be particularly useful
for this purpose (Table 3).
Radiologic criteria
The radiologic criteria, narrowing of and change in
direction of the MC (on a panoramic radiograph) were
the most commonly used indicators of close or intimate
relationship of the MC and the roots (Table 4). Of the
respondents, 31 per cent considered superimposition of
the two structures alone and 24 per cent considered the
radiographic appearance of contact of the roots with
the superior border of the MC alone, in the absence of
any of the other radiologic criteria, as indicators of
close or intimate relationship. The most commonly
used characteristic to indicate the need for CT was
narrowing of the MC (56 per cent), other radiologic
criteria were used by less than half the surgeons
(Table 5).
DISCUSSION
The surgical approach and technique utilized in the
removal of impacted mandibular third molars
contributes
to
the
risk
of
postoperative
dysaesthesia.7,9,13-15,19,21,30,38-41 In some instances, the
knowledge of the precise relationship between the
inferior alveolar nerve and the roots of the mandibular
third molar may be crucial in allowing the appropriate
planning of the procedure in order to minimize the risk
of postoperative dysaesthesia.
It is not surprising that all surgeons use the
panoramic radiograph since it is readily available and
useful for screening purposes as well as in the planning
of the surgical procedure. In relation to the specific use
of the panoramic radiograph for the determination of
the relationship between the MC and the third molar
root, only 25 per cent of the surgeons considered this
modality to be sufficiently accurate. It is therefore
interesting that only 61 per cent of surgeons use CT for
this purpose and that the average frequency of use was
very low (five per cent). It is possible that low CT use
may result from concerns over the radiation doses,
Australian Dental Journal 2006;51:1.

financial costs and difficulty in obtaining CT imaging.

In addition, there are no published studies revealing the
effectiveness of using pre-operative CT imaging on the
degree of patient morbidity and the overall outcome of
third molar surgery. Therefore, it is unclear if the
precise determination of the position and proximity of
the MC using CT imaging is required for safe removal
of third molars with a decrease in patient morbidity.
Further research examining the accuracy and affect on
surgical outcome of the various imaging modalities
should be pursued.
This study also revealed that the nine radiologic
criteria on a panoramic radiograph are used to varying
extents by Australian surgeons as indicators of a close
or intimate relationship between the MC and the roots
of the third molar. Specifically, nearly all surgeons use
change in MC direction and MC narrowing for this
purpose. Of particular interest is that superimposition
of the MC and the root of the third molar alone (31 per
cent) and appearance of contact of the root with the
MC alone (24 per cent) in the absence of any other
radiologic criteria are used as indicators of close or
intimate relationship. Since these two radiologic criteria
have been reported to be present in 4080 per cent of
all impacted mandibular third molars,13,17,19,35 there is
likely a perception that there is a large percentage of
cases where there is a close or intimate relationship.
This in turn may have an effect on the surgical
management of third molar removal. The remaining
five radiologic criteria were used by between 54 and 76
per cent of surgeons.
CONCLUSION
The majority of Australian oral and maxillofacial
surgeons rely upon the panoramic radiograph for the
diagnosis of the proximity of lower third molars to the
MC, even though many did not consider this image to
be the ideal diagnostic tool. Further research examining
the accuracy of the nine radiologic characteristics
(panoramic radiographs) and various imaging
modalities in revealing the true relationship of the MC
to third molar is required. This could be determined by
comparing the accuracy of information from plain
films to that obtained in CT images. This study should
also include observer agreement or reliability in
correctly identifying these characteristics. Finally, a
study of whether the presurgical determination of
proximity and position (buccal or lingual) of the canal
utilizing CT has any usefulness in determining the
surgical protocol and the associated postoperative
morbidity is needed. This has both healthcare cost and
patient radiation exposure implications that will
require further research to explore the cost-benefit ratio
for different populations.
ACKNOWLEDGMENTS
The authors are grateful to Annette Mercer for
assistance in the design of the questionnaire, Professors
Grace Petrikowski, Cameron Clokie, Herenia
Australian Dental Journal 2006;51:1.

Lawrence and John McGeachie for their academic

support and Alice Evans for her secretarial assistance.
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Address for correspondence/reprints:

Associate Professor Marc Tennant
The Centre for Rural and Remote Oral Health
The University of Western Australia
35 Stirling Highway
Crawley, Western Australia 6009
Email: marc@crroh.uwa.edu.au

Australian Dental Journal 2006;51:1.