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ORIGINAL CONTRIBUTIONS

Does 3-dimensional imaging of


the third molar reduce the risk of
experiencing inferior alveolar nerve
injury owing to extraction?
A meta-analysis

Adri Cl-Ovejero, DDS; Alba Snchez-Torres, DDS, MS; ABSTRACT


Octavi Camps-Font, DDS, MS; Cosme Gay-Escoda, MD,
DDS, MS, PhD, EBOS, OMFS; Rui Figueiredo, DDS, MS, Background. Clinicians generally use panoramic radio-
PhD; Eduard Valmaseda-Castelln, DDS, MS, PhD, EBOS graphic (PR) images to assess the proximity of the mandibular
third molar to the inferior alveolar nerve (IAN). However, in
cases in which a patient needs to undergo a third-molar

I
nferior alveolar nerve (IAN) injuries are 1 of the extraction, many clinicians also assess computed tomographic
most critical complications that can occur as a (CT) images to prevent nerve damage.
result of mandibular third-molar (M3M) extrac- Types of Studies Reviewed. Two of the authors inde-
tion1-5; IAN injuries can cause neurosensory pendently searched MEDLINE (through PubMed), Cochrane
impairment of the lower lip and chin area, which clearly Library, Scopus, and Ovid. The authors included randomized
affects the patients quality of life.1 This complication, or nonrandomized longitudinal studies whose investigators
which affects from 0.4% to 5.5%6 of patients, is usually had compared the number of IAN injuries after third-molar
temporary, but on occasion, it also can lead to perma- extraction in patients who had undergone preoperative CT
nent symptoms. The risk of experiencing nerve injury is with patients who had undergone only PR.
higher in cases in which the neurovascular bundle is Results. The authors analyzed the full text of 26 of the 745
exposed during surgery.3,7 articles they initially selected. They included 6 studies in the
Some factors related to the surgical technique and meta-analysis. Four of the studies had a high risk of bias, and
the surgeons experience could have an impact on the the investigators of only 1 study had used blinding with the
patients risk of experiencing IAN injuries.3,7 In patients. The authors observed no statistically signicant dif-
addition, some investigators have described radio- ferences between groups related to the total number of nerve
graphic warning signs.2 The most important predictor injuries (risk ratio, 0.96; 95% condence interval, 0.50 to 1.85;
seems to be the proximity of the M3M roots to the P .91). The prognosis of the injuries was similar for both
mandibular canal (MC).1,6 groups.
Traditionally, clinicians have used panoramic Conclusions and Practical Implications. Although
radiographic (PR) images to assess the relationship having preoperative CT images might be useful for clinicians
between a patients M3M roots and the MC. In in terms of diagnosing and extracting mandibular third mo-
patients who have a high risk of experiencing IAN lars, having these CT images does not reduce patients risk of
injuries, owing to the M3M being in close proximity experiencing IAN injuries nor does it affect their prognosis.
with the MC, clinicians usually recommend obtain- Key Words. Third molar; computed tomography; pano-
ing computed tomographic (CT) images so that the ramic radiography; mandibular nerve; alveolar nerve.
surgeon can have a preoperative, 3-dimensional (3D) JADA 2017:-(-):---
http://dx.doi.org/10.1016/j.adaj.2017.04.001
Copyright 2017 American Dental Association. All rights reserved.

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ORIGINAL CONTRIBUTIONS

view of the area.1 Nevertheless, the investigators of injuries[Mesh]) for MEDLINE (PubMed), (X Ray
some studies have concluded that the use of 3D imaging Computed Tomography Scanner OR Cone Beam
does not seem to reduce the number of nerve injuries.1- Computed Tomography) AND (Third Molar OR
4,6
In addition, 3D imaging is associated with higher Mandibular Nerve) for the Cochrane Library,
costs1,6 and higher levels of radiation exposure (Computed Tomography, X Ray OR Cone Beam
compared with PR.1,4 In spite of these facts, some cli- Computed Tomography) AND (Third Molar OR
nicians systematically indicate obtaining preoperative Mandibular Nerve) for Scopus, and (X Ray
CTs before performing M3M extraction to avoid legal computed tomography or Cone Beam computed to-
issues. Therefore, a meta-analysis of the published data mography) and (Third Molar or Mandibular nerve
would be of great interest to clinicians. Consequently, injury) for Ovid.
the aim of this study was to determine whether We completed the search by manually screening the
obtaining preoperative CT images reduces either the references cited in the selected articles and reviews.
risk of experiencing or the severity of IAN injuries after Selection of studies. Two reviewers (A.C.-O.,
M3M extraction in comparison with obtaining PR A.S.-T.) independently screened the title and abstract of
images. each article to decide its eligibility. They then assessed
the full text of the selected articles. Figure 18 lists the
METHODS studies we removed at this stage and the reasons for
We ensured that the methodology of our study adhered exclusion. A third reviewer (O.C.-F.) resolved any dis-
to the Preferred Reporting Items for Systematic Reviews agreements. We calculated the k statistic to measure the
and Meta-Analyses statement.8 reviewers level of agreement.
Study selection criteria. We included randomized In situations in which the reviewers identied multi-
and nonrandomized controlled trials and prospective ple reports with the same sets of patients, they included
and retrospective cohort studies whose investigators had only the study with the longest follow-up time.
compared the number of IAN injuries that patients Data extraction and method of analysis. Two re-
had experienced after undergoing M3M extraction with viewers (A.C.-O., A.S.-T.) independently extracted the
whether the patients had undergone preoperative CT or data using data extraction tables. Whenever possible,
whether they had undergone only preoperative PR. We they retrieved the following information from the
applied no restrictions regarding language or publication selected articles: names of authors, year of publication,
date. We excluded all of the articles that did not meet country in which the study was conducted, study
these criteria. design, and details associated with the participants,
The main outcome variable was the number of IAN interventions, and outcomes.
injuries for each group; we dened an IAN injury as a We considered the number of IAN injuries to be the
loss of sensation in the lower lip or chin areas, either primary outcome variable. The secondary outcomes
subjectively reported by the patient or assessed by means comprised the type of lesion and the preoperative esti-
of clinical testing. mation of the risk of experiencing nerve injury.
The secondary variables were: Risk of bias assessment. We assessed the risk of bias
- type of lesion: We considered the lesion to be according to the guidelines provided in the Cochrane
persistent if the symptoms lasted longer than 6 months; Handbook for Systematic Reviews of Interventions,
- risk of experiencing nerve injury, estimated by using Version 5.1.0,10 and we performed the data extraction
a previously obtained radiographic assessment: We and meta-analysis with Review Manager software,
classied the level of risk of experiencing IAN injury as Version 5.3 (Cochrane Collaboration). We used the
being moderate if there was a superimposition of the Newcastle-Ottawa Scale11 to assess the cohort studies.
M3M root and the MC, if there was at least 1 radio- Statistical analysis. We carried out the statistical
graphic warning sign (according to Rood and Shehabs analysis using Review Manager software. For dichoto-
criteria9), or both. If we noted that there was more than mous outcomes, we used risk ratios (RR) with 95%
1 radiographic warning sign, we considered that the condence intervals (CI) to estimate the effect of the
patient had a high risk of experiencing IAN injury as a operation. We used parametric and nonparametric tests
result of undergoing M3M extraction. (Pearson c2 test and Fisher exact test) to compare the
Search strategy. We conducted an electronic search groups. We set the level of signicance at a P value of less
of articles published up to March 12, 2017, in MEDLINE than .05.
(PubMed), Cochrane Library, Scopus, and Ovid
databases.
We used the following search strategies for each ABBREVIATION KEY. 3D: 3-dimensional. CT: Computed
database: (((Tomography, X-Ray Computed[Mesh]) tomographic. IAN: Inferior alveolar nerve. M3M: Mandibular
OR Cone-Beam Computed Tomography[Mesh]) AND third molar. MC: Mandibular canal. NR: Not reported. PR:
(Molar, Third[Mesh]) OR Mandibular Nerve/ Panoramic radiographic. RCT: Randomized controlled trial.

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ORIGINAL CONTRIBUTIONS

Records identified Records identified Records identified Records identified


Identification

through MEDLINE through Cochrane through Scopus through Ovid


(PubMed) (n = 298) Library (n = 10) (n = 297) (n = 140)

Records after duplicates removed


(n = 533)
Screening

Records screened Records excluded


(n = 533) (n = 507)

Full-text articles assessed Full-text articles excluded,


for eligibility with reasons (n = 20)
(n = 26) Number of injuries not
Eligibility

specified (n = 4)5,14-16
CT image obtained for all
patients (n = 13)17-29
Case series study
(n = 1)30
Studies included in
Ecological study (n = 1)31
qualitative synthesis
No comparisons made
(n = 6)
between CT and
panoramic radiographic
groups (n = 1)7
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 6)

Figure 1. Flow chart of the article selection process for the systematic review and meta-analysis, according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses statement.8 CT: Computed tomographic.

We performed a meta-analysis only for the studies If we had found a sufcient number of meta-analyzed
whose investigators had compared similar techniques trials (more than 10), we would have performed an
and reported the same outcome measures. We conducted analysis of publication bias, an assessment of clinical
a subgroup analysis taking into consideration the pre- heterogeneity, and an analysis of sensitivity, in accor-
operative risk of experiencing IAN damage. dance with guidelines for analysis by Higgins and
We estimated statistical heterogeneity by means of Thompson.12
using the c2 test (Cochran Q test value) and I2 analyses.
We interpreted a c2 test P value of less than .10 and RESULTS
an I2 value of greater than 50% as having a signicant Study selection and description. As shown in
level of heterogeneity.12 We selected a xed-effects Figure 1,1-8,13-31 the initial electronic search yielded 745
model or a random-effects model according to these references. After we removed duplicates, we screened the
values. abstracts of 533 articles. We selected 26 articles1-7,13-31

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ORIGINAL CONTRIBUTIONS

of some studies included


Guerrero and colleagues,2 2012 + + + + + +
patients that, on the basis
of the results of preop-
Guerrero and colleagues, 2014 3 + + + + + ? erative testing, had a
high risk of experiencing
Ghaeminia and colleagues,1 2015 + + + + + IAN injury.1,6,13 Sanmart-
Garca and colleagues6
Petersen and colleagues, 2016 4 + + + + + + + selected patients whose
PR images showed su-
Korkmaz and colleagues,13 2017 ? + + + + + perimposition of the MC
and the M3M roots, fully

tio as)

po ta ( tion s)

s)

as
formed roots, and the

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as
a

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bi

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presence of at least 1 of

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se on

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tin
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th
7 radiographic signs
ti

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ec

ec

tr
en rm

te

ep
at
el

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described by Rood and
o
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Shehab9 regarding the
es per
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t
lm

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ou sm
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nn
ea
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structures. In addition,
rs

e
co

a
pe

iv
ce

Petersen and colleagues4


e

ct
n

e
en

om
d

et
tio

an
qu

Se
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included patients whose


ca

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se

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ou
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an

PR images showed con-


Al
om

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In
ip
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tact or overlap between


rt

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in

the tooth or root complex


Bl
of

and the MC. We consid-


ng
di

ered the patientss


in
Bl

included in the study by


Petersen and colleagues4
Figure 2. Risk of bias assessment, according to the Cochrane Handbook for Systematic Reviews of Interventions, to have a moderate risk of
Version 5.1.0.10 : Low risk of bias. : High risk of bias. ?: Unclear risk of bias. experiencing IAN injury,
although these authors
for full-text analysis, and we included only 6 articles1-4,6,13 did not classify the patients risk of experiencing injury.
in the meta-analysis. The level of agreement between the In both of their studies, Guerrero and colleagues2,3
reviewers was good, with a k statistic index of 0.909. We selected patients who had a moderate risk of experi-
selected 5 randomized controlled trials (RCT)1-4,13 and 1 encing IAN injury. They excluded patients who they
retrospective cohort study.6 considered to have a high risk (with a high probability
After examining the full text of the 26 articles, we of experiencing harm to the neurovascular bundle) and
excluded 20 of the articles for the following reasons: the low risk (no clear radiographic relationship between
investigators did not specify the number of IAN injuries the M3M and the MC) of experiencing IAN injury.
in each group,5,14-16 the investigators performed CT for Quantitative synthesis. The prevalence of IAN
all patients,17-29 the investigators study design did not neurosensory disturbance was 9.3% (52 of 560) for the
comply with the inclusion criteria (case series30 and CT group and 8.3% (44 of 532) for the PR group. We
ecological design31), and the investigators did not detected persistent neurosensory disturbances in 1.5% of
compare the CT and the PR groups.7 patients (7 of 477) for the CT group and 0.9% (4 of 445)
Risk of bias assessment. We classied 41-3,13 of the 5 for the PR group. Table 2 shows the prevalence of IAN
RCTs1-4,13 as having a high risk of bias, owing to the disturbances according to different preoperative classi-
investigators lack of blinding regarding participants and cations of risk.
personnel1-3,13 and lack of providing incomplete outcome We did not nd statistically signicant differences in
data,1 as shown in Figure 2.1-4,13 the prevalence of IAN injury between the CT and PR
We awarded the retrospective cohort study6 4 points groups (RR, 0.96; 95% CI, 0.50 to 1.85; P .91) or
for the selection category, 1 point for the comparability between the studies whose investigators found that pa-
category, and 3 points for the outcome category, totaling tients had a moderate risk (RR, 1.02; 95% CI, 0.27 to 3.86;
8 points; therefore, we classied the results of the cohort P .97) or a high risk (RR, 0.85; 95% CI, 0.33 to 2.23;
study6 as being of high quality. P .75) of experiencing potential damage (Figure 31,3,4,6,13).
Data extraction. Qualitative synthesis. The in- The investigators of 3 studies found persistent in-
vestigators of the selected studies included different types juries. Ghaeminia and colleagues1 observed 5 lesions in
of patients (Table 11-4,6,13). For example, the investigators the CT group and 2 in the PR group that persisted

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TABLE 1
Characteristics of the studies included in the meta-analysis regarding
participants, interventions, and outcomes.
STUDY PATIENTS INTERVENTIONS OUTCOMES STUDY
DESIGN
Preoperative Assessment Criteria Radiographic Sample Nerve Persistent Persistent
Risk Technique Size (N) Lesions, Lesions (n) Lesion
No. (%) Follow-up
(mo)
Guerrero and Moderate risk Cases that were not considered CT 43 1 (2.3) 0
Colleagues,2 to be high risk (with a high PR 43 1 (2.3) 0
2012 probability of experiencing
harm to the neurovascular
RCT#
bundle) or low risk (no clear NR
(parallel)
radiographic relationship
between the mandibular third
molar and the MC*) of
experiencing IAN injury
Sanmart- High risk Superimposition of roots and CT 95 15 (15.8) 1
Garcia and MC and any 1 of the 7 PR 55 6 (10.9) 1 Cohort
12
Colleagues,6 radiographic warning signs, (retrospective)
2012 cited by Rood and Shehab**
Guerrero and Moderate risk Cases that were not considered CT 126 2 (1.5) NR
Colleagues,3 to be high risk (with a high PR 130 5 (3.8) NR
2014 probability of experiencing
harm to the neurovascular
RCT (parallel,
bundle) or low risk (no clear NR
multicenter)
radiographic relationship
between the mandibular third
molar and the MC) of
experiencing IAN injury
Ghaeminia High risk Superimposition of roots and CT 156 11 (7.1) 5
and MC covering more than one-half PR 164 9 (5.5) 2 8 RCT (parallel)
Colleagues,1 the height of the MC
2015
Petersen and Moderate risk Superimposition of roots and CT 111 21 (18.9) 1
Colleagues,4 MC PR 116 13 (11.2) 1 6 RCT (parallel)
2016
Korkmaz and High risk Close relationship between the CT 72 3 (4.2) 0
Colleagues,13 MC and the third molar, dened PR 67 11 (16.4) 0
2017 as the presence of at least 1 of
the following 6 radiographic
markers: interruption of the
6 RCT (parallel)
white line of the MC, darkening
of the root, narrowing of the MC
or roots, dark and bid roots,
deected roots, diversion of the
MC
* MC: Mandibular canal.
IAN: Inferior alveolar nerve.
CT: Computed tomographic.
PR: Panoramic radiographic.
NR: Not reported.
# RCT: Randomized controlled trial.
** Source: Rood and Shehab.9

after an 8-month follow-up period, whereas Sanmart- P .38) and a moderate risk of experiencing injury (RR,
Garca and colleagues6 and Petersen and colleagues4 each 1.05; 95% CI, 0.07 to 16.50; P .98) (Figure 41,2,4,6,13).
classied only 1 lesion in each group as being persistent
(at least 12 and 6 months of evolution, respectively). DISCUSSION
We did not detect statistically signicant differences in In our study, we failed to nd signicant differences in
persistent lesions (RR, 1.64; 95% CI, 0.50 to 5.41; P .42). the rate of nerve injuries after M3M extraction between
In the subgroup analysis of these persistent injuries, no patients who had undergone preoperative CT and those
differences were found in patients who had a high risk who had not undergone preoperative CT. Unfortunately,
of experiencing injury (RR, 1.82; 95% CI, 0.48 to 6.90; there is no consensus on the criteria for the preoperative

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TABLE 2 support the hypothesis that obtaining preoperative


Percentages of nerve disturbances. CT images does not appear to lead to a signicant
decrease in the rate of IAN injury after M3M
RISK IAN* INJURIES IAN INJURIES extraction.

CT GROUP PR GROUP
Investigators have identied several risk factors
Overall Persistent Overall Persistent
that can predict a patients likelihood of experi-
Moderate 9.7% (23/237) 0.6% (1/154) 7.3% (18/246) 0.6% (1/159) encing IAN injury after M3M extraction. Absence of
High 9.0% (29/323) 1.9% (6/323) 9.1% (26/286) 1.0% (3/286) cortication,20,28 a dumb-bellshaped MC,23,28 and a
Overall 9.3% (52/560) 1.5% (7/477) 8.3% (44/532) 0.9% (4/445) lingual1,22,29 or interradicular29 position of the MC
* IAN: Inferior alveolar nerve. are among these risk factors. Some investigators
CT: Computed tomographic.
PR: Panoramic radiographic. have stated that injuries occur more easily in MCs
that have a narrow conguration.1 In addition, when
the MC is positioned lingually, the IAN may receive
unfavorable forces if the surgeon starts his approach
assessment of the risk of experiencing IAN injury after by luxating on the buccal side.29 For this reason, it is
undergoing third-molar extraction. Indeed, all of the thought that most IAN injuries are the result of
investigators had established their own criteria to classify compression and traction movements during M3M
patients risk, which made it difcult for us to make surgery.17 In cases such as these, preoperative CT images
comparisons. In addition, the time needed to consider a might provide useful information to the surgeon con-
lesion to be permanent also varied. Many investigators cerning where to apply the elevator.
used the term permanent to dene a nerve injury that A signicant proportion (45.5%) of M3Ms have some
had not recovered by the time of the patients nal degree of superimposition over the MC in PR.7
follow-up visit. For this reason, we determined that using According to Nakamori and colleagues,7 this superim-
the term persistent would be more appropriate, position, darkening of the root, and narrowing of
because investigators could not assess the evolution of the MC on PR images correlate with an absence of
the patients injury after the period of data recording cortication7 and suggest close contact between the
concluded. In our meta-analysis, we considered lesions tooth and the nerve. This direct contact, which can be
that lasted more than 6 months to be persistent. We observed in a CT image, seems to be associated with an
selected this time frame because Cheung and colleagues32 increased risk of experiencing IAN injury.19,23 However,
reported that lesions that lasted more than 6 months had owing to this exposure, only those patients who have
a low probability for recovery. Also, Valmaseda-Castelln a true anatomic relationship between the tooth and
and colleagues,33 in the report of their prospective the nerve have a higher risk of experiencing an IAN
cohort study of 1,117 M3M extractions, observed that le- impairment.26
sions that had not recovered 6 months after surgery were Identifying risk factors for IAN injuries is a key issue
very likely to be permanent. involved in a clinicians decision-making process
Drawbacks related to the results of our report include regarding M3M extraction, because identifying these
the fact that both the number of studies and the size risk factors allows the clinician to identify patients who
of the samples were limited and that the results of 4 of have a high risk of experiencing IAN injuries. In-
the RCTs were associated with a high risk of bias. The vestigators have considered the patients age and, espe-
small number of participants included in these RCTs cially, the anatomic proximity of the roots to the MC, to
might have led to a type 2 error (a false-negative result). be the most relevant variables for predicting this
These drawbacks clearly are related to the low incidence complication.17 Clinicians still consider PR to be the
of IAN complications. Indeed, if we dene an IAN injury criterion standard examination for M3M extraction.
after M3M as being the primary outcome and if we Clinicians do not consider the simple superimposition of
consider a 0.5 difference between groups to be clinically the third-molar roots over the MC to be a sign of a close
signicant, favoring the CT group (as proposed by relationship. In fact, the positive predictive value of IAN
Petersen and colleagues4), we nd that none of the injury in cases of superimposition without additional
studies had a statistical power of greater than 70%. features is low. Even when the clinician nds more
Therefore, the results of our meta-analysis strongly specic images, the positive predictive value still remains
indicate the need for researchers to perform RCTs for small, probably owing to the low incidence of this
which they have established a correct calculation of the complication.29,31 Indeed, only approximately 15% of the
statistical power of the study. Clinicians must take patients who undergo M3M extraction and who have
these limitations into account when considering the had preoperative PR images that suggested that the
results of our study. Even with these limitations, the patient has a high risk of experiencing IAN injuries will
outcomes of our meta-analysis and the results of most experience a neurosensory impairment.6 Although CT
of the studies included in our meta-analysis seem to images are more specic for clinicians to detect the true

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CT PR Risk Ratio Risk Ratio


Study or Subgroup Events Total Events Total Weight MH, Random, 95% CI MH, Random, 95% CI

1.1.1 Moderate risk of experiencing potential damage to the IAN


Guerrero and colleagues,3 2014 2 126 5 130 11.3% 0.41 (0.08 to 2.09)
Petersen and colleagues,4 2016 21 111 13 116 27.5% 1.69 (0.89 to 3.20)
Subtotal (95% CI) 237 246 38.9% 1.02 (0.27 to 3.86)
Total events 23 18
2 2 2
Heterogeneity: = 0.61; 1 = 2.53, P = .11; I = 60%
Test for overall effect: z = 0.03 (P = .97)

1.1.2 High risk of experiencing potential damage to the IAN


Sanmarti-Garcia and colleagues,6 2012 15 95 6 55 22.2% 1.45 (0.60 to 3.51)
Ghaeminia and colleagues,1 2015 11 156 9 164 22.9% 1.28 (0.55 to 3.02)
Korkmaz and colleagues,13 2017 3 72 11 67 16.1% 0.25 (0.07 to 0.87)
Subtotal (95% CI) 323 286 61.1% 0.85 (0.33 to 2.23)
Total events 29 26
2 2 2
Heterogeneity: = 0.47; 2 = 5.81, P = .05; I = 66%
Test for overall effect: z = 0.32 (P = .75)

Total (95% CI) 560 532 100.0% 0.96 (0.50 to 1.85)


Total events 52 44
2 2 2
Heterogeneity: = 0.30; 4 = 9.12, P = .06; I = 56%
0.01 0.1 1 10 100
Test for overall effect: z = 0.11 (P = .91)
2 2 Favors CT Favors PR
Test for subgroup differences: 1 = 0.05, P = .83; I = 0%

Figure 3. Meta-analysis: inferior alveolar nerve injury after mandibular third-molar extraction. CI: Condence interval. CT: Computed tomographic.
IAN: Inferior alveolar nerve. M-H: MantelHaenszel. PR: Panoramic radiographic.

CT PR Risk Ratio Risk Ratio


Study or Subgroup Events Total Events Total Weight MH, Fixed, 95% CI MH, Fixed, 95% CI

2.1.1 Moderate risk of experiencing potential damage to the IAN


Guerrero and colleagues,2 2014 0 43 0 43 Not estimable
Petersen and colleagues,4 2016 1 111 1 116 23.3% 1.05 (0.07 to 16.50)
Subtotal (95% CI) 154 159 23.3% 1.05 (0.07 to 16.50)

Total events 1 1
Heterogeneity: Not applicable
Test for overall effect: z = 0.03 (P = .98)

2.1.2 High risk of experiencing potential damage to the IAN


Sanmarti-Garcia and colleagues,6 2012 1 95 1 55 30.2% 0.58 (0.04 to 9.07)
Ghaeminia and colleagues,1 2015 5 156 2 164 46.5% 2.63 (0.52 to 13.35)
Korkmaz and colleagues,13 2017 0 72 0 67 Not estimable
Subtotal (95% CI) 323 286 76.7% 1.82 (0.48 to 6.90)
Total events 6 3
2 2
Heterogeneity: 1 = 0.86, P = .35; I = 0%
Test for overall effect: z = 0.88 (P = .38)

Total (95% CI) 477 445 100.0% 1.64 (0.50 to 5.41)


Total events 7 4
Heterogeneity: 22 = 0.98, P = .061; I2 = 0%
Test for overall effect: z = 0.81 (P = .42) 0.01 0.1 1 10 100
2 2
Test for subgroup differences: 1 = 0.13, P = .72; I = 0%
Favors CT Favors PR

Figure 4. Meta-analysis: persistent inferior alveolar nerve injury after mandibular third-molar extraction. CI: Condence interval. CT: Computed
tomographic. IAN: Inferior alveolar nerve. M-H: MantelHaenszel. PR: Panoramic radiographic.

anatomic relationship between M3Ms and MCs, the impairment when 3D techniques are used, compared
positive predictive value of CT images is still low and, to with conventional PR.
our knowledge, there are no data suggesting that there According to the results of this meta-analysis, clini-
would be any reduction in the prevalence of IAN cians should not perform CT routinely before M3M

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ORIGINAL CONTRIBUTIONS

surgery. However, in specic cases in which the clinician imaging or cone beam CT scanning: a randomized controlled trial (RCT).
Dentomaxillofac Radiol. 2016;45(2):20150224.
suspects a close relationship between the MC and the 5. Gallesio C, Berrone M, Ruga E, Boffano P. Surgical extraction of
M3M after observing PR images, we recommend impacted inferior third molars at risk for inferior alveolar nerve injury.
obtaining CT images.18 J Craniofac Surg. 2010;21(6):2003-2007.
6. Sanmart-Garcia G, Valmaseda-Castelln E, Gay-Escoda C. Does
CONCLUSIONS computed tomography prevent inferior alveolar nerve injuries caused by
lower third molar removal? J Oral Maxillofac Surg. 2012;70(1):5-11.
According to the results of our meta-analysis, clinicians 7. Nakamori K, Fujiwara K, Miyazaki A, et al. Clinical assessment of the
should not perform CT routinely before M3M surgery relationship between the third molar and the inferior alveolar canal using
because using CT images does not seem to reduce the panoramic images and computed tomography. J Oral Maxillofac Surg.
2008;66(11):2308-2313.
incidence or affect the patients prognosis of IAN injuries 8. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
in comparison with using PR images. n Preferred reporting items for systematic reviews and meta-analyses: the
PRISMA Statement. PLoS Med. 2009;6(7):e1000097.
Dr. Cl-Ovejero is a fellow, Master of Oral Surgery and Orofacial 9. Rood JP, Shehab BA. The radiological prediction of inferior alveolar
Implantology, Faculty of Medicine and Health Sciences, University of nerve injury during third molar surgery. Br J Oral Maxillofac Surg. 1990;
Barcelona, Barcelona, Spain. 28(1):20-25.
Dr. Snchez-Torres is a graduate of the Master of Oral Surgery and 10. Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews
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of Medicine and Health Sciences, University of Barcelona, Barcelona; and a Collaboration; 2011. Available at: www.handbook.cochrane.org. Accessed
researcher, Bellvitge Biomedical Research Institute, Barcelona, Spain. April 14, 2017.
Dr. Camps-Font is a graduate of the Master of Oral Surgery and Orofacial 11. Wells GA, Shea B, OConnell D, et al. The Newcastle-Ottawa Scale
Implantology, and an associate professor of oral surgery, Faculty of Medi- (NOS) for assessing the quality of nonrandomised studies in meta-
cine and Health Sciences, University of Barcelona, Barcelona; and a analyses. The Ottawa Hospital Research Institute; 2014. Available at: www.
researcher, Bellvitge Biomedical Research Institute, Barcelona, Spain. ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed April 14,
Dr. Gay-Escoda is the chair and a professor, Oral and Maxillofacial 2017.
Surgery, Faculty of Medicine and Health Sciences, University of Barcelona, 12. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-
Barcelona; the director of the Master Degree Program in Oral Surgery and analysis. Stat Med. 2002;21(11):1539-1558.
Implantology, EFHRE (European Foundation for Health Research and 13. Korkmaz YT, Kaypmaz S, Senel FC, Atasoy KT, Gumrukcu Z. Does
Education) International University/FUCSO (Catalonian Foundation for additional cone beam computed tomography decrease the risk of inferior
Oral Health); a coordinator and researcher, Bellvitge Biomedical Research alveolar nerve injury in high-risk cases undergoing third molar surgery?
Institute, Barcelona; and the head, Department of Maxillofacial Surgery and Does CBCT decrease the risk of IAN injury? Int J Oral Maxillofac Surg.
Implantology, Teknon Medical Center, Barcelona, Spain. 2017;46(5):628-635.
Dr. Figueiredo is an associate professor, Oral Surgery, Faculty of Medicine 14. Sigron GR, Pourmand PP, Mache B, Stadlinger B, Locher MC. The
and Health Sciences, University of Barcelona, Barcelona; and a researcher, most common complications after wisdom-tooth removal, part 1: a
Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain. retrospective study of 1,199 cases in the mandible. Swiss Dent J. 2014;124(10):
Address correspondence to Dr. Figueiredo at Faculty of Medicine and 1042-1046, 1052-1056.
Health Sciences, Campus de Bellvitge, C/Feixa Llarga, s/n; Pavell Govern, 15. Roeder F, Wachtlin D, Schulze R. Necessity of 3D visualization for the
2a planta, Despatx 2.9, 08907 LHospitalet de Llobregat, University of Bar- removal of lower wisdom teeth: required sample size to prove non-
celona, Barcelona, Spain, e-mail rui@ruibf.com. inferiority of panoramic radiography compared to CBCT. Clin Oral
Dr. Valmaseda-Castelln is a professor, Oral Surgery, and a professor, Investig. 2012;16(3):699-706.
Master of Oral Surgery and Orofacial Implantology, Faculty of Medicine 16. Ghaeminia H, Meijer GJ, Soehardi A, et al. The use of cone beam CT
and Health Sciences, University of Barcelona, Barcelona; and a researcher, for the removal of wisdom teeth changes the surgical approach compared
Bellvitge Biomedical Research Institute, Barcelona, Spain. with panoramic radiography: a pilot study. Int J Oral Maxillofac Surg. 2011;
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Disclosure. None of the authors reported any disclosures. 17. Selvi F, Dodson TB, Nattestad A, Robertson K, Tolstunov L. Factors
that are associated with injury to the inferior alveolar nerve in high-risk
ORCID Number. Rui Figueiredo: http://orcid.org/0000-0002-2122-6530 patients after removal of third molars. Br J Oral Maxillofac Surg. 2013;51(8):
868-873.
The authors conducted this study in association with the Odontological 18. Hasegawa T, Ri S, Shigeta T, et al. Risk factors associated with inferior
and Maxillofacial Pathology and Therapeutics Research Group of the alveolar nerve injury after extraction of the mandibular third molar: a
Bellvitge Biomedical Research Institute. comparative study of preoperative images by panoramic radiography and
computed tomography. Int J Oral Maxillofac Surg. 2013;42(7):843-851.
The authors thank Mary Georgina Hardinge for her assistance in 19. Xu GZ, Yang C, Fan XD, et al. Anatomic relationship between
correcting the English in the manuscript. impacted third mandibular molar and the mandibular canal as the risk
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