Cortical integrity of the inferior alveolar canal as a predictor of paresthesia after third-molar extraction

Wonse Park, DDS, MSD; Ji-Wook Choi, DDS; Jae-Young Kim, DDS; Bong-Chul Kim, DDS; Hyung Jun Kim, DDS, MSD, PhD; Sang-Hwy Lee, DDS, MSD, PhD

JADA, Vol. 141 http://jada.ada.org March 2010 271

Presented by Andhika Priyatama

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Background
Extraction of mandibular third molar Damage of the inferior alveolar nerve Direct Damage =

Paresthesia

Panoramic Radiography Used for evaluating nerve damage

position
angulation Proximity of IAN

Disanvantage: limited 3-D visualization relatively poor diagnostic accuracy when used to examine anatomical forms and structures. (Bell and colleagues) Page 2

Background
CT (Computed Tomography) Provide 3D info of IAN and MTM Bucolingual configuration Curvature and number of roots Cortical loss of IAC Distance IAN & MTM

Most consistent finding that visible on CT image

evaluate the relationship between the paresthesia that occur as complication of MTM extraction and the cortical integrity of the IAC as viewed via CT

Purposes

help predict potential damage to the IAN during MTM extraction evaluated the usefulness of cortical interruption as a possible risk factor in, or predictor of, IAN injury and resulting paresPage 3 thesia after MTM extraction.

Participants, Methods and Material

Participants: patients At Department of Oral and Maxillofacial Surgery or the Department of General Dentistry at the Yonsei University Dental Hospital (2004 and 2007) for the evaluation and management of impacted MTMs.

Panoramic Radiography

revealed any evidence of increased risk of nerve damage

Preoperative CT Imaging
Excluded: patients with pathological lession Free Powerpoint Templates

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Participants, Methods and Material

Variables:
primary: the cortical integrity of the IAC

secondary: the number of CT image slices containing evidence of loss of cortical integrity

primary: the presence or absence of paresthesia after MTM extraction.

Tooth Assignment
group 1,
no contact between the root or crown of the MTM and the IAC (Figure, A and B);.

group 2,
contact between the root of the MTM and the intact IAC cortex (Figure, C and D);

group 3,

contact with the interrupted cortex, the IAC contacted the root of the MTM with interruption of the cortex Free Powerpoint Templates (Figure, E and F).

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Participants, Methods and Material

Methods:
Oral surgeons checked patients for signs of paresthesia on the first day and the seventh day after surgery
comparing the sensitivities of the affected and unaffected sides using neurological perception tests for the IAN

cold pin- prick brush stroke two-point discrimination

paresthesia,
follow-up evaluation every week for three weeks and then monthly evaluations there- after.

Free Powerpoint Templates

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Participants, Methods and Material

Result
179 participants

mean age 23.6 years 47.5 percent male

MTM extraction (259 MTMs extracted).

Most impaction horizontal.

Free Powerpoint Templates Page 7

Participants, Methods and Material

Result
Groups 1 and 2 together included only one case of paresthesia, group 3 had 10 cases (11.8 percent).

Free Powerpoint Templates

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Participants, Methods and Material

Result
Table 3 summarizes the relationship between cortical integrity and paresthesia

reclassifed the predictor variable cortical integrity

intact

disrupted

Free Powerpoint Templates

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Participants, Methods and Material

Result
Table 4 details the prevalence of paresthesia according to the position of the MTM incidence of paresthesia differed significantly with the position of the IAC relative to the MTM

incidence of post- operative paresthesia was greater for the lingually positioned IAC relative to the crown and root of the MTM compared with the apical or buccal positions (seven of 66 cases).

Free Powerpoint Templates

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Participants, Methods and Material

Result

group 3 (interrupted cortex), the incidence of paresthesia increased markedly

the number of CT images observed cortical disruption exceeded three slices Free Powerpoint Templates

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Discussion
occurrence of paresthesia after MTM extraction

rare
relationship

distressing experience for the patient and the clinician

paresthesia after MTM extraction

cortical integrity of the IAC as viewed on CT imaging

cortical integrity is a viable prognostic marker for paresthesia after MTM extraction
Free Powerpoint Templates Page 12

Discussion
prevalence of paresthesia
group 3 (participants who had an interrupted cortical lining)
higher (11.8 percent)

the other two groups,

the frequency of nerve damage

the number of CT image slices

showing loss of cortical integrity.

Free Powerpoint Templates

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Discussion
Pathway
absence of cortical continuity in the IAC -As viewed on CTdirect contact between the IAN and the MTM,

injury or exposure of the nerve during MTM extraction

valuable prognostic indicator of IAN injury.

Integrity of canal is important to IAN Damage

Free Powerpoint Templates Page 14

Discussion
First Predictor variable secondary predictor variable
cortical integrity, the predictor variable, is an important factor in predicting postoperative paresthesia.
prevalence of paresthesia increased significantly when more than three consecutive CT image slices exhibited evidence of cortical interruption.

When the cortical interruption as viewed on CT imaging exceeded approximately 3 mm, the risk of IAN damage increased to more than 20 percent. Free Powerpoint Templates

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Recommendation
use of CT only when the oral and maxillofacial clinicians observed a definite radiographic sign of paresthesia on prior panoramic radiography.

Rood and Shehab (1990) summarize radiological predictors of IAN injury three critical radiographic signs:

diversion of the IAC,

darkening of the root interruption of the radiopaque lines of the IAC. Page 16

Free Powerpoint Templates

Conclusion
cortical interruption of the IAC (as viewed on CT imaging)
direct contact between the IAN and the MTM than if the cortex was intact.

higher risk of experiencing paresthesia after MTM extraction

clinician can estimate

degree of contact between the nerve and the tooth

number of CT images that show cortical interruption

Free Powerpoint Templates effective predictor of possible injury

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MATUR NUWUN

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