J Oral Maxillofac Surg

65:1303-1308, 2007

Third Molar Position: Reliability of

Panoramic Radiography
Yoichi Nakagawa, DDS, PhD,* Hisako Ishii, DDS, PhD,
Yoshiaki Nomura, DDS, PhD,
Nobuyuki Y. Watanabe, DDS, PhD, Daigo Hoshiba, DDS,
Kaoru Kobayashi, DDS, PhD, and
Katsunori Ishibashi, DDS, PhD#

Purpose: The purpose of the present study was to determine whether panoramic radiographs could

predict physical contact between the mandibular third molar and the mandibular canal on limited
cone-beam computed tomography, known as dental 3D-CT (3-dimensional computed tomography
[3D-CT]).
Patients and Methods: The association of images between the panoramic radiograph and the dental
3D-CT was investigated in a cross-sectional study. Seventy-three lower third molars in 65 patients were
examined. Findings of absence or presence of the white line of the mandibular canal wall on panoramic
radiographs and contact or separation between the tooth and the mandibular canal on dental 3D-CT were
compared.
Results: Absence of a superior white line on panoramic radiography was associated with an increased
risk of contact between the third molar and the mandibular canal on dental 3D-CT, even when the effects
of tooth position, age, and gender were taken into account. The multivariate adjusted odds ratio was
10.79. Women were more likely to have contact between the 2 structures on dental 3D-CT when their
panoramic radiograph showed absence of the white line.
Conclusions: Panoramic radiography is useful for predicting to a limited extent physical contact
between the mandibular third molar and the mandibular canal on dental 3D-CT.
2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:1303-1308, 2007
Injury to the sensory nerve bundle is a frequent and
serious complication associated with the extraction
of impacted mandibular third molars. The incidence
of inferior alveolar nerve damage after lower third
molar extraction ranges from 0.5% to 8% and is usually around 5%.1 Several factors that influence nerve
damage have been discussed in the literature, including surgical technique, method of anesthesia, patient
age, position of the third molar, and relationship between the mandibular canal and the third molar.1-3
Above all, precise preoperative evaluation of the
Received from the Tsurumi University School of Dental Medicine,
Yokohama, Japan.
*Assistant Professor, Second Department of Oral and Maxillofacial Surgery.
Visiting Assistant Professor, Second Department of Oral and
Maxillofacial Surgery.
Assistant Professor, Department of Preventive Dentistry and
Public Health.
Visiting Researcher, Second Department of Oral and Maxillofacial Surgery.
Staff, Second Department of Oral and Maxillofacial Surgery.
Professor, Department of Oral Radiology.

proximity of the mandibular canal to the third molar

is essential in the extraction of third molars.
Several specific signs on panoramic radiography
have been used as indicators of close proximity of the
mandibular canal to the third molar.4 Moreover, 4
radiographic signs darkening of the root, interruption of the white lines, diversion of the mandibular
canal, and narrowing of the rootare recognized to
be associated with inferior alveolar nerve exposure
that occurs after mandibular third molar extraction.1,5,6
#Professor, Second Department of Oral and Maxillofacial Surgery.
This investigation was supported in part by a grant-in-aid for
High Technology Research Centers from the Ministry of Education,
Culture, Sports, Science, and Technology.
Address correspondence and reprint requests to Dr Nakagawa:
Department of Oral and Maxillofacial Surgery, Tsurumi University
School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama,
230-8501 Japan; e-mail: nakagawa-y@tsurumi-u.ac.jp
2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6507-0007$32.00/0
doi:10.1016/j.joms.2006.10.028

1303

1304
Conventional cross-sectional tomography and computed tomography (CT) are more useful for evaluation of the 3-dimensional (3D) location of the mandibular canal in relation to the mandibular third molar
than is panoramic radiography.7-10 Recently, limited
cone-beam x-ray CT, which consists of a cone beam
and a 2-dimensional x-ray sensor, has been used for
the diagnosis of jaw lesions.1,11-13 Limited cone-beam
CT has the advantages of high resolution and low
radiation dose,11 and it is recognized as a useful preoperative examination tool in tooth extraction.13 Further, limited cone-beam CT clearly shows cortication
of the mandibular canal.13,14
Although CT is a useful tool in minor oral surgery,
clinicians remain reluctant to use it routinely because
of the additional radiation exposure involved. If panoramic findings could accurately predict the 3D relationship between the mandibular canal and the third
molar, CT would not be needed. However, only a few
studies have compared panoramic radiography versus
tomography in this regard.9,15
The purpose of the present study was to determine whether panoramic radiography could predict physical contact between the mandibular third
molar and the mandibular canal. The hypothesis
was that when the white line of the mandibular
canal is absent from the panoramic radiograph, the
mandibular canal is in contact with the mandibular
third molara condition that increases the occurrence of inferior alveolar nerve injury in tooth extraction. Conversely, these structures should be
completely separate when the superior white line is
clearly visible on the panoramic radiograph. To
investigate this hypothesis, the presence or absence of the mandibular canal white line on panoramic radiographs was compared with corresponding images from limited cone-beam CT.

Patients and Methods

STUDY DESIGN

The association of images on panoramic radiography and limited cone-beam CT imaging was investigated in a cross-sectional study.
SELECTION OF CASES

Sixty-five Japanese patients (a total of 73 teeth)

were selected from patients who visited the Second
Department of Oral and Maxillofacial Surgery at
Tsurumi University Dental Hospital between 2000
and 2001 for extraction of lower third molars.
When panoramic radiography indicated that the
tooth was superimposed on the mandibular canal,
limited cone-beam CT examination was performed,
with the patients consent. This study involved con-

MANDIBULAR CANAL AND THIRD MOLAR RADIOGRAPHY

FIGURE 1. Classification of radiopacity of the white line on panoramic radiography. Absence, the superior white line is not visible or
interrupted; Presence, the superior white line is distinct in the area in
which the canal and the tooth are superimposed.
Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

secutive patients whose teeth underwent panoramic and limited cone-beam CT imaging during a
2-year period. All patients understood the purpose
of the examination and gave investigators permission to use the data obtained. Patients with teeth
that had a cyst or dental caries with chronic periapical granuloma were excluded from the study. The
Committee for Ethics at Tsurumi University approved this study protocol.
PANORAMIC RADIOGRAPHY IMAGING SYSTEM

Panoramic radiographs were taken in standardized

scanning modes with an Auto 1000 (Asahi Roentgen)
and were digitalized by FCR AC-3-HQ (Fuji Photofilm,
Tokyo, Japan).
LIMITED CONE-BEAM CT IMAGING SYSTEM

The limited cone-beam CT apparatus used was a

PSR 9000 (Asahi Roentgen), which consists of a conebeamtype CT scanner and a small x-ray image intensifier.13 This type of apparatus is known as dental
3-dimensional CT (3D-CT). A single scan provides 365
slices of axial projection data with a slice thickness of
0.117 mm; further, sectional images can be obtained
in any direction and from any layer. Cross-sectional
images perpendicular to the panoramic images (sections parallel to the dental arch) were used in this
study.
IMAGING ASSESSMENT

Findings of absence or presence of the mandibular canal wall on panoramic radiography and contact between the tooth and the mandibular canal on
dental 3D-CT were evaluated by an oral surgeon
(Y.N.) and an oral radiologist (K.K.), according to
the criteria described later. Both observers had 20
years of experience in their respective fields. When

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NAKAGAWA ET AL

Table 1. STATISTICAL CORRELATION BETWEEN PREDICTIVE VARIABLES AND DENTAL 3D-CT

Dental 3D-CT

Radiopaque line of canal wall

Angulation of tooth

Degree of tooth impaction

Gender

Presence
Absence
Horizontal
Vertical
Mesioangular
Distoangular
A
B
C
Male
Female

Total

Contact

Separate

Total

20
36
26
7
21
2
4
37
15
17
39
56

11
6
7
5
5
0
4
10
3
12
5
17

31
42
33
12
26
2
8
47
18
29
44
73

P Value
.034
.362

.154
.003

Abbreviation: 3D-CT, 3-dimensional computed tomography.

Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

disagreement occurred between the assessments of

the 2 evaluators, a consensus was reached by discussion. Interobserver agreement was evaluated
through kappa statistics.
ASSESSMENT OF THE MANDIBULAR CANAL ON
PANORAMIC RADIOGRAPHY

Radiopacity of the white lines, that is, the radiopaque lines constituting the roof (superior) and
floor (inferior) of the mandibular canal, was observed
on panoramic radiography. Images were classified
into 2 groups (absence and presence) according
to the visibility of the superior white line (Fig 1). An
interrupted white line4 was classified as absence.
Only the area in which the canal and the tooth were
superimposed was used for observation.
ASSESSMENT OF THE POSITION OF THE THIRD
MOLAR ON PANORAMIC RADIOGRAPHY

The degree of impaction was classified according

to the relative depth of the third molar within the
bone. In Class A impaction, the crown of the third
molar is located at the same level as the occlusal
plane of the second molar. In Class B, the third
molar is found between the occlusal plane and the
cervical line of the second molar. In Class C, the
impacted tooth is below the cervical line of the
second molar.
Teeth were also categorized into the following 4
groups according to tooth angle: horizontal, vertical,
mesioangular, and distoangular.
ASSESSMENT OF THE RELATIONSHIP BETWEEN THE
CANAL AND THE THIRD MOLAR ON DENTAL 3D-CT

The physical relationship between the third molar

and the mandibular canal was classified into 2 types:
separation and contact. In the separation type, no

interruption of the radiolucent canal wall is recognized because the mandibular canal does not come
into contact with the tooth. Even when part of the
entire circumferential canal wall is not clearly visible,
the mandibular canal is completely separated from
the third molar.
STATISTICAL ANALYSIS

Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS), version
14.0 (SPSS Inc, Tokyo, Japan). Cross-tabulations and
2 tests were carried out on factors investigated in
this study. Logistic regression analysis was used to
evaluate the individual contributions of panoramic
findings, gender, and age. Crude and multivariate adjusted odds ratios and their associated 95% confidence intervals were calculated. The outcome variable was defined as the point of contact between the
third molar and the mandibular canal on CT, and the
predictor variable referred to the absence of mandibular canal wall on panoramic radiography. Other variables such as age, gender, and position of the third
molar on panoramic radiography were regarded as
confounding factors.
Sensitivity, specificity, and positive and negative
predictive values were calculated for contact on CT
imaging.
Decision analysis was carried out through the
quaternion estimation (QUEST) algorithm and Answer
Tree, version 3.1 (SPSS Inc). Contact and separation
on dental 3D-CT were used as objective variables.
Kappa values were calculated for interobserver
agreement. A kappa value less than 0.40 was considered to indicate poor agreement; 0.40 to 0.59, fair
agreement; 0.60 to 0.74, good agreement; and 0.75 to
1.00, excellent agreement.

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MANDIBULAR CANAL AND THIRD MOLAR RADIOGRAPHY

Table 2. STATISTICAL CORRELATION BETWEEN AGE AND DENTAL 3D-CT IMAGES

Age (yr)

Dental 3D-CT

Contact
Separate
Total

Mean

SD

P Value

56
17
73

32.4
36.1
33.3

10.5
18.25
12.65

.964

Abbreviations: 3D-CT, 3-dimensional computed tomography; SD, standard deviation.

Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

Results
RELIABILITY

Interobserver agreements were excellent: the

kappa value in the assessment of presence or absence
of the mandibular canal wall on panoramic radiography was 0.752, and that in the assessment of contact
or separation on CT was 1.00.
SUMMARY STATISTICS

A total of 73 lower third molars were examined in

65 patients (26 men and 39 women; age range, 17 to
75 years; mean age, 33.98 13.16 years; 74% of
patients were aged 20 to 39 years).
Of 73 teeth investigated in this study, 56 (76.7%)
showed contact between the third molar and the
mandibular canal on dental 3D-CT, and 17 showed
separation (Table 1).
Among 42 cases in which the superior white line
of the canal was absent on panoramic radiography,
36 (85.7%) exhibited contact between the roots of
the third molar and the mandibular canal on dental
3D-CT. Sensitivity was calculated as the probability

that cases in which CT images showed contact

would have an absent superior white line on panoramic radiography (0.64; 36 of 56). Specificity,
which refers to the proportion of cases with separation on CT in which the superior white line was
present on panoramic radiography, showed a similar value (0.65; 11 of 17). Although the positive
predictive value (probability that the root and the
mandibular canal were in contact in the absence of
a distinct superior white line) was 0.86 (36 of 42),
the negative predictive value was 0.35 (11 of 31).
This suggests difficulty in predicting whether or not
the root was in contact with the mandibular canal
when panoramic radiography showed the presence
of a superior white line.
Cross-tabulations were carried out for dental 3D-CT
and factors investigated in this study. As shown in
Table 1, findings on panoramic radiography and gender had a statistically significant correlation with CT
findings, as determined by the 2 test. No significant
correlation between age and dental 3D-CT image was
found (Table 2). Thus, gender is a potential confounder.

Table 3. CONTRIBUTIONS OF PANORAMIC FINDINGS, AGE, AND GENDER TO CONTACT BETWEEN THE THIRD
MOLAR TOOTH AND THE MANDIBULAR CANAL ON DENTAL 3D-CT ACCORDING TO THE LOGISTIC REGRESSION
ANALYSIS

Radiopaque line of
canal wall
Angulation of tooth

Degree of tooth
impaction

Absence/Presence
Horizontal
Vertical
Mesioangular
A
B
C

Age
Gender

Female/Male

Crude
Odds
Ratio
3.117
Reference
group
2.653
0.884
Reference
group
0.270
0.231
1.022
5.236

95% CI

P
Value

Multivariate
Adjusted
Odds Ratio

95% CI

P
Value

0.9999.723

.050

10.793

1.91460.859

.007

.302

.330

0.64210.965
0.2453.192

.178
.851
.214

4.346
1.380

0.62830.090
0.2906.564

.137
.686
.102

0.0571.726
0.0361.497
0.9821.063
1.58717.241

.098
.124
.291
.007

0.148
0.074
1.056
9.955

0.0201.104
0.0060.873
1.0001.115
2.16045.455

.062
.039
.051
.003

Abbreviations: 3D-CT, 3-dimensional computed tomography; CI, confidence interval.

Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

NAKAGAWA ET AL

FIGURE 2. Decision tree for evaluating contact between the third

molar and the mandibular canal on computed tomography imaging.
Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

THE INFLUENCE OF VARIABLES OF PANORAMIC

FINDINGS, AGE, AND GENDER ON CONTACT AS
SEEN ON DENTAL 3D-CT IMAGING

To obviate the problem of confounding factors,

logistic regression analysis was carried out to calculate crude and multivariate adjusted odds ratios (Table
3). Results showed that the absence of a white line on
panoramic radiography was associated with increased
risk of contact between the third molar and the mandibular canal on dental 3D-CT, even when the effects
of tooth position, age, and gender were taken into
account.
To consider clinical usefulness and clinical decision
making, decision analysis was carried out with the
QUEST algorithm because the equation obtained by
logistic regression analysis does not seem to be easy
to use in daily clinical practice. The decision tree
showed that the highest-risk patient was a woman
whose panoramic radiograph showed absence of the
mandibular canal wall (Fig 2).

1307
No previous studies have proved a relationship
between cortication of the mandibular canal on panoramic radiography and that on cross-sectional conventional tomography.9 Conversely, in a CT study,
several signs on panoramic radiography were highly
predictive of contact between the third molar and the
mandibular canal; these included increased radiolucency of the root and narrowing and interruption of
the radiopaque mandibular canal.15 In the present
study, investigators focused on interruption of the
panoramic radiopacity of the mandibular canal
through the use of limited cone-beam CT imaging as
the standard. Positive and negative predictive values
suggested a high probability that the mandibular canal
and the tooth were seen to be in contact on CT
imaging, even when the superior white line was
clearly visible on panoramic radiography. When the
superior white line is invisible on panoramic radiography, the possibility of contact between the mandibular canal and the dental root is enhanced. Thus,
careful surgical extraction of the teeth is recommended in cases in which the mandibular canal is
superimposed on the dental root.
Among 31 cases in which the superior white line of
the canal was distinctly present on panoramic radiography, 20 (64.5%) showed contact between the roots
of the third molar and the mandibular canal on dental
3D-CT. This rate was unexpectedly high. Such results
depend on the cortication of the superior canal wall.
When cortication of the superior wall of the mandibular canal remains intact (Fig 3A), producing high
density on CT, the panoramic radiograph should depict a distinct white line for the canal. In this situation, although the mandibular canal and the third
molar root are in contact, the root interrupts only a
small portion of the canal wall. Conversely, when the
third molar root is attached to the superior wall of the
canal, and the superior wall of the mandibular canal
shows up as defective on CT (Fig 3B), the panoramic
radiograph should depict absence of the white line of

Discussion
Results reported here suggest that panoramic radiography may be used to predict to a limited extent
contact between the third molar and the mandibular
canal. When the superior white line was indistinct,
the root was more likely to be in contact with the
superior canal. The multivariate adjusted odds ratio
was 10.79. However, results also showed the difficulty involved in predicting whether the root contacts the mandibular canal when panoramic radiography shows the presence of a superior white line.

FIGURE 3. Diagram of relationship between the third molar and the

mandibular canal on computed tomography imaging. A, The superior
portion of the canal is intact. B, The superior portion of the canal is
eroded by the tooth. C, The superior portion of the canal shows low
density.
Nakagawa et al. Mandibular Canal and Third Molar Radiography. J Oral Maxillofac Surg 2007.

1308
the canal. When the superior wall of the canal has low
density on CT imaging (Fig 3C), the white line of the
canal is absent on panoramic radiography. The relationship shown in Figure 3A may predominate when
contact occurs between the roots of the third molar
and the mandibular canal on dental 3D-CT, and when
panoramic radiography distinctly shows the superior
white line of the canal. The presence or absence of
the superior white line of the canal on panoramic
radiography may be related to the extent of cortication of the superior wall of the mandibular canal.
Results of this study indicate that women had a
higher probability than men that the mandibular canal
and the third molar would be in contact when the
panoramic radiograph showed absence of the white
line. One of the reasons for this inherent risk among
women may be the buccolingual thickness of the
mandibular bone. With a thinner mandible (which
women have), less distance is likely to be seen between the tooth and the mandibular canal.
Attention must be paid to the presence or absence
of the superior mandibular white line on panoramic
radiography in mandibular third molar extraction. Patients at highest risk for inferior alveolar nerve damage are women whose panoramic radiographs show
absence of the superior white line.

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