The purpose of this study was to find a correlation between the use of a CBCT prior to the surgical removal of lower mandibular third molars and the postoperative outcome in terms of neurological disorders. The analysis of this correlation is necessary, because surgeons need reliable data when informing the patient about possible risks of a surgical procedure. We hypothesised that utilizing preoperative three-dimensional radiographs would lower the amount of iatrogenic nerve injuries. In our study, 13 out of 324 patients (2.6%) suffered from neurological damage after surgery. To put this number into perspective, we searched international literature for studies, stating the amount of iatrogenic nerve injuries during the removal of lower mandibular third molars. Regardless of the complexity of the extraction, literature shows a wide range in surgery risk varying between 0.8% and 8.4%. 2,17 In 2006, Jeries analysed the occurrence of neurological impairment during lower mandibular third molar surgical in a prospective study with a comparably high number of patients (1087 cases). Patients in this study only underwent two-dimensional imaging in form of an OPT. The occurrence of temporary neurological disorders was stated at 4.1%, while permanent damage occurred in 0.7%. 18 Multiple study parameters of Jeries’ were equal or similar to our study, but it has to be considered that the average difficulty of the lower third molar extraction in Jeries’ case is lower than in our study, since in our case all two-dimensional radiographs showed signs of increased risk to the IAN. In our opinion, the amount of nerve injuries in complex cases with a preoperative CBCT (2.6%) is comparably high, when looking at a risk of 4.8% for cases with only an OPT.
The clinical exposure of the IAN bundle during the surgical removal of lower third molars depends on many factors, e.g. maximum mouth opening, intraoperative bleeding and nonetheless the location and route of the IAN. In the past, authors have correlated intraoperative exposure of the IAN and neurological damage. 5 Our study presents, that there is no significant correlation between both. Only in two cases with postoperative neurologic deficiencies the IAN was visible to the surgeon. One of these nerve routes was caudal, the other one was interradicular, which can be described as a subtype of caudal. It appears logical, that a surgeon rather takes notice of an IAN if its route is caudal (touching) and that a vestibular nerve can rarely be seen due to the perspective of the surgeon. Leung states, that a neurological deficit is 14.9 times more likely when the IAN bundle is exposed during the procedure. 12 The review includes the buccal approach, lingual split technique and coronectomy. The surgical approach also has great impact on a possible exposure of the IAN bundle. It is necessary to specify the surgical approach when searching for a possible correlation with complications.
A major factor influencing the outcome of a study is the surgeon. His experience and skill level as well as his physical and mental state influence every possible statistic. In this study, surgery was performed by six different oral surgeons with varying skill levels and experience.
Postoperative swelling as well as the reception of pain are extremely difficult to objectify. In this study it was necessary to rely on patient documentation only. To achieve a more distinct and objective picture of postoperative swelling and pain, a prospective study with predesigned standardised questionnaires and medical reports is necessary.
Damage to the IAN can result in anaesthesia, paraesthesia, pain, or a combination of the three. 19,20 Some patients do not recognise the hypoesthesia until the sensory field is objectively tested. To objectify postoperative hypoesthesia, the receptive field of the IAN was tested on every patient one day after surgery by testing the sharp-dull discrimination and two-point discrimination of the receptive field. The analysis of pain reception, postoperative swelling and tests on the receptive field add up to a detailed data pool that allows a comprehensive interpretation.
The lack of accuracy when using only an OPT for preoperative diagnostics has been described by many authors in the past. 5, 21-23 Before CBCT diagnostics were available, radiological signs in two-dimensional diagnostics were indication for a CT-Scan. Even though CT diagnostics have been available since 1972, clinicians in dentistry have not used computed tomography routinely, mainly, due to an initial lack of access to the machines and due to the comparably high radiation exposure. 24 The production of smaller and more affordable CBCT devices in the early 2000s gave dentists and maxillofacial surgeons the ability of cost effective three-dimensional diagnostics combined with a low radiation exposure for patients and medical staff. 25-28
Today, multi-detector computed tomography (MDCT) and low-dose protocols result in much lower radiation exposure during CT diagnostics. The effective dose of a MDCT can be as low as 0.15 mSv, dropping below effective doses of some CBCT devices. Still, with a sub-millimetre spatial resolution, the CBCT is the preferable imaging technique for dentoalveolar diagnostics. 22
Compared to about 22 μSv effective dose of an OPT, CBCTs still cause much higher radiation exposure than two dimensional radiographs, which is why CBCT should not be considered for standard diagnostics, but only if the OPT shows risk factors for IAN damage. 21,29,30 If theire is a postoperative loss of sensory function of the IAN Bundel the magnetic resonance imaging (MRI) ist still the best examination for proving a IAN bundle damage. 31
The complete removal of a lower third molar by buccal approach is probably the most common, but not the only therapy option, when indication for surgery is confirmed. Several authors proclaim coronectomy as the approach of choice, when the lower third molar is in proximity of the inferior alveolar nerve. 32-34 While the benefit of coronectomy versus complete extraction is controversially discussed in literature, indications and contraindications of the procedure have been defined clearly. 2,32 One contraindication for a coronectomy is the horizontal rotation of the lower third molar. Our data shows, that a horizontally rotated lower third molar (Winter) in proximity to the inferior alveolar nerve (OPT) results in no significant correlation with postoperative sensitivity impairment. It can be concluded, that if contraindication for coronectomy is present due to a horizontal rotation, complete extraction should be the procedure of choice.
The CBCT is also of significance when evaluating the removal indication of symptom-free lower third molars. The indication for surgery should be revaluated if the CBCT shows a caudal touching or interradicular route.