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YIJOM-2463; No of Pages 6

Int. J. Oral Maxillofac. Surg. 2012; xxx: xxxxxx


http://dx.doi.org/10.1016/j.ijom.2012.06.018, available online at http://www.sciencedirect.com

Clinical Study
Oral Surgery

Darkening of third molar roots


on panoramic radiographs: is it
really predominantly thickening
of the lingual cortex?

J. Szalma1, L. Vajta1, E. Lempel2,


S. Jeges3, L. Olasz1
1

Department of Oral and Maxillofacial


Surgery, University of Pecs, Hungary;
Department of Restorative Dentistry and
Periodontology, University of Pecs, Hungary;
3
Department of Biostatistics and Medical
Informatics, Faculty of Health Sciences,
University of Pecs, Hungary
2

J. Szalma, L. Vajta, E. Lempel, S. Jeges, L. Olasz: Darkening of third molar roots on


panoramic radiographs: is it really predominantly thickening of the lingual cortex?.
Int. J. Oral Maxillofac. Surg. 2012; xxx: xxxxxx. # 2012 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. This study investigated the exact intra-alveolar aetiology of a panoramic
high-risk sign, darkening of the third molar roots. 83 mandibular third molar
surgical removals demonstrating dark bands on the third molar roots in preoperative
radiographs were included in this prospective study. Exposure of the inferior
alveolar nerve (IAN), the root morphology of the third molar (e.g. groove or hook)
and the integrity of the mandibular canal or lingual cortical wall were observed.
Differences between single (increased radiolucency alone) and multiple darkening
cases (increased radiolucency with accompanying high risk signs) and between
IAN exposure and groove formation were analysed. In 38 cases (45.8%), the IAN
was visible during the operation. Groove was present in 37.4% of cases. 26.5% of
the cases showed lingual cortical thickening, while specious root conformation
explained the formation of darkening on the radiographic images of an additional
9.6% of the cases. IAN exposure (P < 0.001) and groove formation (P < 0.001)
were significantly more frequent in multiple darkening cases than in single
darkening cases. According to these findings, darkening of the third molar roots is
more often the result of fenestration of the inferior alveolar canal wall or groove
formation of the root than lingual cortical thickening.

Preoperative risk assessment of neurosensory disturbances before third molar surgery is essential. Panoramic radiography is
widely accepted and used because of its
advantages (cost effectiveness and low
radiation levels).13 The values of different
high risk markers and specific signs have
been evaluated and discussed to some
extent. Darkening of third molar roots on
0901-5027/000001+06 $36.00/0

panoramic radiographs was proved by several authors to be one of the strongest


classic specific signs indicating a close
anatomic relationship between the third
molar roots and the inferior alveolar canal
(IAC).311 In addition, Leung and Cheung3
stated that only darkening of the root was
significantly related to postoperative inferior alveolar nerve (IAN) deficit.

Key words: third molar; panoramic radiography; inferior alveolar nerve; darkening of the
root.
Accepted for publication 22 June 2012

hman et al.13 conBundy et al.12 and O


cluded that this radiolucent band is the
result of root material loss (groove on the
root) caused by the IAC, whereas Tantanapornkul et al. stated, according to their cone
beam computed tomographic (CBCT) findings, that dark banding on panoramic radiographs is the sign of lingual cortical
thickening.11

# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

YIJOM-2463; No of Pages 6

Szalma et al.

The exact formation of this sign seems to


be multi-causal. The results of the authors
earlier investigations suggested a significant difference between so-called single
and multiple appearances of dark bands
on the third molar roots in relation to
IAN exposure.9 Multiple darkening was
defined as a dark band across the root with
other simultaneous adjacent high risk signs
(e.g. interruption of the superior cortical
line of the canal and diversion of the canal
or narrowing of the canal), and IAN exposure was seen significantly more frequently
in these cases.9 Plenty of radiological investigations (including CT and CBCT) have
dealt with image analysis of the different
high risk radiographic markers, including
the darkening sign11,1317; but direct visual
information on intra-operative intra-alveolar findings and on root conformation connected to that sign is incomplete.
The authors aim was to examine the
exact morphology of the third molar roots,
the integrity of the IAC and the visible
thinning or fenestration of the lingual
cortical wall of the alveolus when the
preoperative
panoramic
radiograph
showed darkening of the root.
Materials and methods

This prospective study included 83 patients


(39 males and 44 females) with a mean age
of 28.1  6.7 years (range 1648 years).
Inclusion criteria were patients with

darkening of the root on preoperative


radiographs. Darkening was defined as a
radiolucent band on the root of the third
molar, where the IAC crosses it. Isolated/
single darkening was defined as darkening
of the root without adjacent panoramic
signs. Multiple darkening was defined as
darkening of the root and one or more of the
adjacent panoramic radiographic signs
simultaneously (diversion of the canal, narrowing of the canal, and interruption of the
superior cortical line; illustrated in Szalma
et al.9,10).
Patients without darkening on preoperative radiographs were excluded from the
study. All the patients underwent surgery in
the authors department (Department of
Oral and Maxillofacial Surgery, University
of Pecs, Pecs, Hungary) between January
2010 and September 2011. Prior to operation, each patient provided full informed
consent. The study was approved by the
Regional Research Ethics Committee of the
Medical Center, Pecs (Ref. No. 3795.3167851/KK4/2010).
Third molar removals were carried out
under local anaesthesia. Envelope (sulcular) mucoperiosteal flaps were raised at
superficial impactions, and triangular flaps
were raised at deep impactions, followed
by vestibular and distal bone removal. The
sockets were irrigated with 20 ml of sterile
saline solution at room temperature, and
the alveoli (especially the IAN exposure,
root morphology, groove formation and

visible lingual cortical defects, perforations or thickening) were checked during


and after precisely focused, careful suction. If excessive bleeding made intraoperative observation ambiguous, the case
was excluded from the study. The exposed
IAN bundles were examined under loupe
magnification using a headlight. An IAN
exposure was defined upon direct visualization of the suspected neurovascular bundle when the following criteria were
partially or totally fulfilled: mesiodistally
oriented tubular, pale or whitish structure at
the expected level of the socket (estimated
according to the panoramic radiographs).
The criteria for lingual cortical thickening
were a regularly or irregularly shaped dark
area on the lingual surface of the alveolus,
with or without an impression caused by the
third molar. Soft tissues on the lingual
surface lacking a tubular shape and lacking
mesiodistal orientation were determined to
be fenestration of the lingual cortical wall.
The root morphology was observed from
both mesiodistal and buccolingual directions after removal. If the reconstruction of
fractured or segmented roots was not possible, the case was excluded.
When the IAN was visible, iodoformimpregnated drains were placed at the
suture insertion to prevent possible nerve
compression. Whenever possible, patient
documentation included macro-photographs (Canon EOS 500D, Canon EF
100 mm f/2.8 USM macro objective;

Fig. 1. The occurrence of different aetiological factors resulting in darkening on panoramic radiographs, according to the authors observations.

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

YIJOM-2463; No of Pages 6

Darkening of third molar roots on panoramic radiographs


Canon Macro Ring Lite MR-14EX,
Canon, USA).
Digital panoramic radiographs (PaX400C with a maximum sensor resolution
of 10.42 line pairs/mm, Vatech, Korea)
were taken before surgery. Preoperative
radiographs and the presence of the high
risk sign, darkening of the root (with or
without adjacent high risk signs) were
analysed by the first two authors (J.Sz.)
and (L.V.). For preoperative panoramic
image analysis, the Easydent (Vatech,
Korea) software was used. Observations
were conducted on a laptop computer (HP
Pavilion dv5; 1280  800 maximum resolution). Image manipulation using the
enhancement tools of the viewer-solution
(magnification, contrast, brightness,
sharpness, inverted colourization) was
permitted. Ambient light during observation was reduced to less than 50 lx. Intraand inter-observer reliabilities were tested
by kappa statistics.

Statistical analysis

Data collection and statistical analysis were


carried out with SPSS 18.0 (SPSS Inc.,
Chicago, USA) software. Associations of
single and multiple darkening cases with
the presence of nerve exposure or with the
presence of groove/hook formation were
tested by Pearsons x2 test. A P value less
than 0.05 was considered to be significant.
Cohens kappa statistic was used to calculate observer agreement. A kappa value of
less than 0.40 was considered to show poor
agreement, a value of 0.400.59 was considered to be fair agreement, a value of
0.600.74 was considered to be good agreement, and a value of 0.751.00 was considered to be excellent agreement.
Results

Both the intra- and inter-observer reliabilities were excellent in this study. There
were no statistical differences between the

single and multiple study groups for age


and gender (P = 0.09 and P = 0.13). Overall, 47 patients presented multiple root
darkening on panoramic radiographs,
and 36 patients showed single darkening.
Of the 83 extractions, the IAN was visible
in 37 cases (38/83, 45.8%), broken down
30 times (30/83, 36.2%) in multiple darkening cases and 8 times (8/83, 9.6%) in
single darkening patients. The localization
of the visible IAN was: 10.8% buccal (4/
37 cases), 40.6% inferior or inter-radicular
(15/37 cases) and 48.6% lingual (18/37
cases). Groove or hook formation was
observed 25 times in multiple darkening
cases (25/47, 53.2%) and 6 times in single
darkening cases (6/36, 16.7%). All
grooves were localized on the lingual
surfaces of the third molar roots or were
positioned inter- or intra-radicularly.
The occurrence and frequency of different aetiological factors of dark band genesis
are presented in Fig. 1. IAN exposure

Fig. 2. (a and b) 25-Year-old female patient with left lower impacted third molar. Darkening of the root (single darkening) developed because the
mesiobuccal root was curved and shorter than the mesiolingual root.

Fig. 3. (a) 36-Year-old female patient with left mandibular impacted third molar, with single darkening of the root. (b) The buccal and lingual
roots were superimposed. (c) Mesiodistal view of the tooth shows that the shorter buccal root explained the development of the darkening.

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

YIJOM-2463; No of Pages 6

Szalma et al.

(missing canal wall) with or without groove


formation of the root was the most frequent
reason for darkening (45.8%), while visible
lingual cortical thickening was observed in
26.5% of the cases. In 9.6% of the cases,
special root conformation (imitating darkening, Figs 2 and 3) was observed without
any nerve exposure or cortical deficiency,

while 18.1% of the cases had no obvious


reason for the genesis of darkening.
Both IAN exposure (P < 0.001, x2 test)
and groove formation (P < 0.001, x2 test)
were significantly more frequent in multiple darkening than in single darkening
cases. Reversible paresthesia occurred in
1 patient (1/83, 1.2%) observed at suture

removal, and the sensory disturbance


resolved completely within the first 3
weeks.
Discussion

Proper screening of high risk patients


before impacted third molar surgery is

Fig. 4. (a and b) Despite the notable groove on the lingual surface of the root (arrow), no darkening was seen at the expected height of the root in
the panoramic radiograph, supporting the hypothesis that grooves might be present without radiological consequences.

Fig. 5. (ac) Different appearances of intra- and inter-radicular grooves with the impression of the dental canal. In (c), the arrow indicates the
prepared cavity for improved retention for the Barry elevator. (d) The crop of the panoramic radiograph represents multiple darkening (darkening
with slight narrowing of the canal) of the root. (e) The exposed IAN was seen lingually (arrow). (f) A marked groove (almost a hook) was seen on
the lingual surface of the root.

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

YIJOM-2463; No of Pages 6

Darkening of third molar roots on panoramic radiographs


crucial. The determination of risky cases
based on different panoramic radiographic
signs is widely accepted, but judgements
on the usefulness of these markers vary on
a broad scale. Although these markers
should indicate the close anatomical relationship between the IAC/IAN and the
third molar,18 the explanation of their
aetiology is not uniform in the literature.
The most interesting debate surrounds the
development of the sign referred to as
darkening of the third molar root. This
sign appears on panoramic radiographs
as a dark band, also known as increased
radiolucency, across the roots of a third
molar.
Rood and Noraldeen Sheehab19 stated
that darkening of the root is an impingement of the root where the canal crosses it,
whereas they suggested that loss of the
cortical lining of the canal is possible as
well. Bundy et al. described this sign as
evidence for root material loss of the third
hman et al. stated that groove
molars.12 O
formation of the root appears on radiographs as a dark band, whereas this sign

can be present without grooves.13 Monaco


et al.15 found (in 73% of increased radiolucency cases) direct contact between the
third molar root and the mandibular canal
hman et al.13
on axial CT scans, and O
found it in 100% according to coronal CT
scans.
Mahasantipiya et al.14 first mentioned
the possibility that darkening may be present because of lingual cortical thickening,
while Tantanapornkul et al.11 later clearly
concluded that the majority (80%) of darkening cases showed lingual cortical thickening in CBCT images, in contrast with
20% caused by grooves. Susarla et al.17
estimated the correlation between interrupted cortical walls of IAC and IAN exposures using panoramic radiography, CT
scans and intraoperative observations.
They showed that the IAN exposure group
had significantly bigger defects of the IAC
wall. They observed 31 IAN exposures
showing significant (3 mm) cortical
defects of the IAC from the 80 evaluated
high risk third molar extraction cases
in their study. The frequency of IAN

exposures (38.8%) representing IAC cortical wall deficiency in their study correlates with the present results, but Susarla
et al. did not publish any information on the
concurrent panoramic signs in that study.17
The present results indicate that grooving
of the root occurred more frequently
(37.4%) among darkening cases than indicated in the study by Tantanapornkul
et al.11 (20%), whereas it did not reach
hman
the frequency stated in the study by O
13
et al. (63%). In another 8.4% of the
darkening cases in the present study, IAN
exposure was present with IAC wall deficiency but without grooving of the root.
Additionally, special root conformation,
which imitated darkening of the root on
radiographs, had a notable 9.6% rate of
occurrence. Neither Mahasantipiya et al.
nor Tantanapornkul et al. had described
this as an possible alternative.11,14 Clinically proven lingual cortical thickening or
fenestration appeared in 26.5% of the present cases, which is approximately onethird of that concluded by Tantanapornkul
et al.11 according to their CT observations.

Fig. 6. (a) 27-Year-old female patient with impacted lower third molar with single darkening. (b) Note the exposed IAN on the lingual surface
(arrow). (c) A groove was observed on the lingual surface of the root tip (arrow). (d) The lingual cortical thickening is remarkable (arrow). The
combination of a missing canal wall, a groove on the root and a thicker lingual cortical wall resulted in the increased radiolucency.

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

YIJOM-2463; No of Pages 6

Szalma et al.

Additionally, grooving without darkening


has been experienced in the authors practice (Fig. 4), but it did not occur during the
study period.
According to the authors observations,
the formation of a band of increased radiolucency includes the following possible
causes: missing buccal and/or lingual cortex/s of the IAC wall; grooving or hook
formation of the root (Fig. 5); perforation
or thickening of the lingual cortical wall
(Fig. 6d); special root conformations imitating root darkening (Figs 2 and 3), and a
combination of the above-mentioned conditions (Fig. 6).
The authors earlier and recent results
suggest that single darkening cases should
be distinguished from multiple darkening
cases.9 In their opinion, multiple darkening improves the risk assessment due to
the possibility of false-positive errors, for
which darkening is just the result of some
lingual cortical thickening or tricky root
conformation, but accompanying high
risk markers (e.g. interruption of the
superior cortical line of the canal and
diversion of the canal or narrowing of
the canal) indicate a true risk for IAN
exposure during surgery.
The authors clinical investigation did
not illustrate the sixth possibility of the
genesis of darkening, namely lingual cortical thickening cases caused by a lingually
transpositioned IAC. The theoretical occurrence of the above-mentioned possibility
was 18.1% in this study.
In conclusion, darkening of the third
molar root was considered to be mainly
the result of a missing IAC wall resulting
in IAN exposure (45.8%), with adjacent
grooving of the root in 81.6% of these
cases. Lingual cortical thickening was
proven in 26.5% of the darkening
cases, while unique root conformation
mimicked darkening in 9.6% of the cases.
Multiple darkening indicated a significantly higher risk for IAN exposure and
groove formation than single darkening.
These results disagree with Tantanapornkul et al.,11 who observed grooving in
20% of the cases with darkening on the
hman et al.,13
panoramic images, and O
who stated that darkening in 63% of the
cases was caused by grooving. Further
studies combining panoramic radiography, CT/CBCT and intraoperative observations on a larger study population
should be conducted to investigate these
results in more detail.

Funding

None.
Competing interests

None declared.
Ethical approval

Not required.
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Address:
Jozsef Szalma
Department of Oral and Maxillofacial
Surgery
University of Pecs
5 Dischka Gy Street
Pecs H-7621
Hungary
Tel: +36 72 535924;
Fax: +36 72 535905
E-mail: jozsef.szalma@aok.pte.hu

Please cite this article in press as: Szalma J, et al. Darkening of third molar roots on panoramic radiographs: is it really predominantly
thickening of the lingual cortex? Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.06.018

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