Inferior alveolar nerve injury related to mandibular third molar surgery: An unusual case presentation

Nicholas A. Drage, BDS, FDSRCS, DDRRCR,a and Tara Renton, BDS, MDSc, FDS RCS, FRACDS, FRACDS(OMS),b London, United Kingdom
KINGS COLLEGE

Perforation of the lower third molar roots by the inferior alveolar nerve is uncommon and can be difficult to determine by conventional radiographic methods. Presented is a case of perforation that was treated by coronectomy, and showed an unusual complication in that the retained root erupted, moving the canal with it. The radiographic assessment of root perforation and the imaging modalities used to assess such cases are discussed. (Oral Surg Oral Med Oral Pathol Oral Radiol

Endod 2002;93:358-61)

One of the risk factors for inferior alveolar nerve (IAN) injury following lower third molar surgery is the proximity of the roots to the inferior dental canal (IDC).1-8 This feature is identified by 3 radiological features: diversion of the canal, darkening of the root, and interruption of the canal walls. It can be recognized on periapical and panoramic views.4,5,7,9 There have been previous reports of third molar perforation by the IDC,4,5,9-11 but perforation is difficult to confirm unless cross-sectional imaging is used. We present a case report of perforation where cross-sectional imaging helped to achieve the diagnosis. This case also demonstrates an unusual complication of mandibular third molar root retention when perforated by the IDC.
CASE REPORT
A 32-year-old woman was referred to the Department of Oral and Maxillofacial Surgery by her general dental practitioner for the completion of removal of her lower right third molar (Fig 1). The general dental practitioner had attempted to remove the right mandibular third molar, but it proved difficult and eventually resulted in a root fracture. The patient was fit and well. She reported anesthesia and paresthesia of the right lower lip and chin. Review of the preoperative panoramic radiograph showed a mesioangularly impacted lower-left wisdom tooth with a radiolucent band across the roots (Fig 1). In view of the likely association between the nerve and the roots, additional imaging was performed with the use of a Scanora unit (Soredex Corporation, Helsinki, Finland) to localize the inferior alveolar canal. The panoramic radiograph
aLecturer

in Dental Radiology, Department of Dental Radiology, Guys, Kings & St Thomas Dental Institute, Kings College. bSenior Clinical Research Fellow Department of Oral & Maxillofacial Surgery, Guys, Kings & St Thomas Dental Institute, Kings College. Received for publication Jun 4, 2001; returned for revision Jul 18, 2001; accepted for publication Aug 27, 2001. 2002 Mosby, Inc. All rights reserved. 1079-2104/2002/$35.00 + 0 7/16/120895 doi:10.1067/moe.2002.120895

(Fig 2) confirmed the radiolucent banding of canal across the root fragment and the widening of the ligament space consistent with luxation of the tooth. There was also an irregular opacity measuring approximately 3 mm in diameter distal to the last standing molar tooth that represented part of pack that the dentist had placed. Cross-sectional images suggested that the IDC perforated the root (Fig 3). After discussion with the patient, the root fragment was left in situ and the patient was reviewed 3 months later. At this time the paresthesia was resolving. The patient was then lost to follow up but returned 8 years later with an acute infection in the lower right third molar region. The area had been symptomatic for about 8 months with progressive discomfort. There was renewed paresthesia of the right chin and lower lip, which had been present 4 months. The original paresthesia resolved 4 years after the attempted extraction. This paresthesia was thought to be due to infection affecting the nerve. Radiographs showed the retained root had erupted in the intervening 8-year period. There was a radiolucency surrounding the root and a generalized increased density of the bone. These findings are compatible with the sclerosing osteitis within the bone. The radiolucent banding was still present on the root, and the corticated lines of the IDC adjacent to the root were redirected superiorly, consistent with the root moving with the inferior dental canal through the bone (Fig 4). The outline of the canal could not be seen within the radiolucency surrounding the root because the infective process had destroyed it. The root was removed with the patient under general anesthesia, and during operation the IAN was found to be perforating the root. There was no bony canal surrounding the bundle within the granulation tissue. The tooth was sectioned to free it from inferior dental bundle. The nerve was undamaged macroscopically by this procedure and was later repositioned below a buccal mucosal flap. Two weeks after the procedure the distribution of the paresthesia was similar to the preoperative neural examination, and 4 months later the search for a resolution continued.

DISCUSSION
It is estimated that the incidence of perforation is 1 in 800 impactions.4 Howe and Poyton,9 in a very large

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Fig 1. Cropped panoramic radiograph showing the mesioangularly impacted wisdom tooth preoperatively.

Fig 2. Cropped panoramic radiograph demonstrating the close association of the inferior dental canal and the luxated root fragment.

retrospective study of 1355 wisdom teeth, suggested 3 radiographic signs of perforation: radiolucent band crossing the root above the apex, loss of both radiopaque borders of the canal where it crosses the root, and constriction of the canal in the middle of the root. Rud4,5 investigated 22 and 60 grooved or perforated mandibular third molars and retrospectively assessed the relative radiographic features. Thirty-eight percent of teeth displayed loss of both canal tramlines, 11% loss of superior tram line, 5% narrowing of canal and 9% showed no specific features. When the white lines of the canal are unbroken, it is unlikely that any grooving or perforation is present. The white lines are lost when the borders of the canal are encroached upon by the tooth.9 Therefore, in cases of perforation, both white lines would be lost. In cases where the apex is grooved by the canal only, the superior line is lost and the inferior line remains intact. There is increased radiolucent banding present because there is a sudden decrease in the amount of tooth substance present at this point. Perforation happens because the forming roots grow and surround the canal. Narrowing of the canal is not possible to explain fully because the formative dental papilla is soft and the bone surrounding the canal is dense. This probably explains why narrowing of the canal is an uncommon feature.9 A method proposed to manage these cases is coronectomy,12-15 since it helps to prevent damage to the IAN. The majority of roots remain quiescent, but occasionally the root fragments migrate to the alveolar crest. This is an advantage because the fragments are further away from the nerve, which makes removal of the fragments easier.12-14 A review of past literature

revealed no examples of a root erupting with an attached IDC. Although coronectomy was not planned for this patient, it occurred because the crown fractured during the procedure leaving the root in situ. Root fracture during extraction of wisdom teeth occurs with an incidence of between 3% and 4.9%.12,16 It is common practice to leave vital root fragments in situ as most heal uneventfully,16,17 but extraction is recommended if it has been disturbed in the socket.15 Various radiographic methods have been used to ascertain the position of the IDC in relation to the roots of the wisdom tooth. Radiographic views such as the periapicals, panoramic, and oblique lateral views are often requested to show the impacted wisdom teeth. However, from a single view it is impossible to ascertain the relationship of the canal to the tooth. A view taken at right angles such as a mandibular 90 occlusion may show the canal, but the teeth can be superimposed over the area of interest and so localization is difficult. A posterior-anterior view of the mandible could be useful for those IDCs that are buccally placed but are ineffective for the cases where the canal is close to the roots. Again, there is a problem with superimposition. Parallax18,19 has been used to determine the position of the nerve with respect to the root apex. However, absolute position cannot be determined, and it can be technically difficult to produce good quality films. It is not always easy to take periapical films in this region because of patient gagging. Techniques such as stereo radiography19,20 rely on the tube shift principle and are easier to perform, however, the downside is that interpreting the images requires special training.22

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Fig 4. Cropped panoramic radiograph showing movement of the root and the ID canal. There is also a radiolucent area around the root surrounded by a densely sclerotic area, in keeping with long standing chronic infection.

Fig 3. Cross-sectional image through the root fragment confirming perforation of the root by the ID canal.

Linear tomography23-25 has the ability to display the mandible in cross-section showing the exact position of relevant structures. CT has similar advantages and is accurate in demonstrating the course of the inferior dental canal.25 The disadvantage of CT is the relatively high radiation dose and cost. In this case the tomographic slices were obtained on the Scanora unit with the use of spiral tomography with a slice thickness of 4 mm. The movement of the x-ray tube comprises 8 spirals, and the image quality is superior to linear tomography. An exciting new development in imaging is tuned aperture computed tomography (TACT). This modality

is based on the optical aperture theory and provides 3dimensional information from multiple 2-dimensional radiographic projections.26 In vitro studies have examined its use before implant placement,27,28 and it appears to be a promising alternative to conventional tomographic systems.28 It has also been used in determining the orientation of roots to the IAC. In this respect, the best acquisition was made by using vertical, conical, and x-shaped beam arrays.29 However, more studies are needed to evaluate its use in patients. With the use of standard radiographic criteria, a periapical or panoramic radiograph is adequate in most cases to identify whether the IDC is in close association with a tooth.4,5,7,9 Cross-sectional imaging by spiral tomography or CT can be used to determine the exact position of the canal. Coronectomy is an acceptable method of managing the perforated root, but occasionally the root fragment retains its eruptive potential.

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Reprint requests: Nicholas Drage, BDS, FDSRCS, DDRRCR Department of Dental Radiology Floor 23, Guys Tower Guys Hospital London SE1 9RT United Kingdom

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