applied

sciences
Article
Anatomical Risk Factors of Inferior Alveolar Nerve Injury
Association with Surgical Extraction of Mandibular Third
Molar in Korean Population
Hee Jin Kim 1 , Ye Joon Jo 1 , Jun Seok Choi 1 , Hyo Joon Kim 2 , Jin Kim 2 and Seong Yong Moon 2, *

1 Department of Oral and Maxillofacial Surgery, Chosun University Dental Hospital, Gwangju 61452, Korea;
[email protected] (H.J.K.); [email protected] (Y.J.J.); [email protected] (J.S.C.)
2 Department of Oral and Maxillofacial Surgery, College of Dentistry, Chosun University, Gwangju 61452,
Korea; [email protected] (H.J.K.); [email protected] (J.K.)
* Correspondence: [email protected]

Abstract: The purpose of this study was to analyze the incidence and risk factors of possible inferior
alveolar nerve (IAN) injury after extraction of the mandibular third molars. A total of 6182 patients
were examined for 10,310 mandibular third molar teeth. Panoramic radiography and patients’ medi-
cal records were used to analyze age, gender, and impaction pattern of the mandibular third molar.
Cone beam computed tomography (CBCT) was used to investigate the detailed pathway of the infe-
rior alveolar nerve and evaluated the presence of symptoms of nerve damage after tooth extraction.
In CBCT, 6283 cases (61%) of the inferior alveolar nerve were actually in contact with the root of
the mandibular third molar. The correlation with the panoramic signs of root darkening (p < 0.001),
root deflection (p < 0.001), interruption of the IAN (p < 0.001), diversion of the IAN (p < 0.001), and





 narrowing of the IAN (p < 0.001) had statistical significance. Of the 4708 patients who underwent
surgical extraction, 31 (0.658%) complained of nerve damage. Among them, 30 patients (0.637%)
Citation: Kim, H.J.; Jo, Y.J.; Choi, J.S.;
complained of symptoms of inferior alveolar nerve damage, and 1 patient (0.02%) complained of
Kim, H.J.; Kim, J.; Moon, S.Y.
symptoms of lingual nerve damage. There was a significant correlation with IAN injury in cases
Anatomical Risk Factors of Inferior
Alveolar Nerve Injury Association
where the roots became dark at the IAN area (p = 0.018) and there was diversion of the IAN at the
with Surgical Extraction of root area (p = 0.041). When the narrowing of the IAN and the lingual driving pathway of the inferior
Mandibular Third Molar in Korean alveolar nerve appeared simultaneously in CBCT, the risk of IAN injury was high.
Population. Appl. Sci. 2021, 11, 816.
https://doi.org/10.3390/ Keywords: third molar; inferior alveolar nerve; third molar extraction; impacted mandibular third
app11020816 molar; CBCT

Received: 17 December 2020

Accepted: 12 January 2021
Published: 16 January 2021 1. Introduction
The third molar is the most commonly impacted tooth. Several causes can lead to
Publisher’s Note: MDPI stays neutral
impaction of the mandibular third molars. Eruption can be interfered by local physical
with regard to jurisdictional claims in
barriers such as adjacent teeth, dense bones, excessive soft tissue, and lesions [1]. The
published maps and institutional affil-
prevalence of impacted third molars has been reported in the range of 30.3% to 68.6% [2–6].
iations.
The extraction of the mandibular third molar is one of the most common surgeries in
oral and maxillofacial surgery [7,8]. Complications that can occur when extracting the
mandibular third molar include damage to the adjacent teeth, swelling, bleeding, infection,
and nerve damage. Among the potential complications associated with removal of the third
Copyright: © 2021 by the authors. molar, inferior alveolar nerve (IAN) injury is a representative complication. Several studies
Licensee MDPI, Basel, Switzerland.
have reported an incidence of IAN injury of 0.26–8.4% [9–15]. Various factors such as
This article is an open access article
the age of the patient, the experience of the surgeon, and the extent and location of the
distributed under the terms and
impaction are discussed as the risk factors of the nerve injury [15–17].
conditions of the Creative Commons
The most important risk factor for IAN injury is the correlation between the anatomical
Attribution (CC BY) license (https://
position of the third molar and the proximity of the IAN [12,18]. Panoramic radiographs are
creativecommons.org/licenses/by/
4.0/).
widely used for initial examination to assess the third molar. However, it is not possible to

Appl. Sci. 2021, 11, 816. https://doi.org/10.3390/app11020816 https://www.mdpi.com/journal/applsci

Appl. Sci. 2021, 11, 816 2 of 16

accurately determine the buccal and lingual positioning of the third molar and nerves on
a two-dimensional panoramic radiograph. Therefore, it is not easy to assess the possibility of
nerve injury from panoramic radiographs [19]. There have been many studies regarding the
correlation between the mandibular third molar and the IAN, and the signs that can predict
the possibility of IAN injury using a two-dimensional panoramic radiograph [20]. Previous
studies have reported a correlation between some panoramic signals and nerve injury,
but the results are not unified [21–30]. In order to overcome the limitations of panoramic
radiographs, the use of cone beam computed tomography (CBCT) has recently increased.
CBCT is very useful for the evaluation of impacted mandibular third molars [31] and the
proximity of the IAN, and to improve the risk assessment prior to surgery [32].
Panoramic signals of IAN contacts have shown frequently, however, the occurrence
of IAN injury is rare and it is very hard to predict nerve injury. The purpose of this study
was to analyze the incidence and risk factors of possible IAN injury after extraction of the
mandibular third molars. CBCT and panoramic radiography was used to evaluate the
factors that may have affected inferior alveolar nerve injury.

2. Patients and Methods

This study was conducted with the approval of the Institutional Review Board (IRB)
(CUDHIRB 1902 006) from 1st Jan 2016 to 31th Mar 2020 in patients who presented with
a mandibular third molar. They underwent panoramic radiography as well as CBCT. The
CBCT used an Aquilion ONE CT system (Aquilion One, Canon Medical Systems, Otawara,
Japan). The scanning conditions were as follows: Tube images demonstrated an expansile
lesion obstructing the entire left maxillary sinus just below the current 250 mA, tube poten-
tial was 120 kV, scanning time was 0.5 s/scan, and slice thickness was 0.5 mm. Patients
with alveolar bone pathologies, craniofacial deformities such as Down syndrome or clei-
docranial dysplasia, and cases with low quality panoramic radiography and CBCT were
excluded. A total of 6182 patients were examined out of 10,310 patients with mandibular
third molar teeth.

2.1. The Impaction Pattern of the Mandibular Third Molar

The panoramic radiography and patients’ medical records were used to analyze age,
gender, and the impaction pattern of the mandibular third molar. In this study, two main
classification criteria were applied to determine the impaction pattern of the mandibular
third molars.

2.1.1. Pell and Gregory Classification

According to the Pell and Gregory classification [33], the impacted mandibular third
molars were classified into three stages according to the depth of impaction with regards to
the adjacent teeth: (1) Class A, when the highest point of the occlusal surface of the impacted
mandibular third molar is at the same height as the occlusal surface of the adjacent tooth;
(2) Class B, when the highest point of the occlusal surface of the impacted mandibular third
molar is between the occlusal surface of the adjacent tooth and the cervical line; and (3) Class
C, when the highest point of the occlusal surface of the impacted mandibular third molar
is below the cervical line of the adjacent tooth. In addition, Classes I, II, and III were classified
by the distance between the anterior margin of the ascending mandibular ramus and the
distal surface of the mandibular second molars: (4) Class I, when the distance from the
anterior margin of the ascending mandibular ramus to the distal surface of the mandibular
second molar is wider than the width of the occlusal surface of the impacted mandibular
third molar; (5) Class II, when the distance from the anterior margin of the ascending
mandibular ramus to the distal surface of the mandibular second molar is narrower than the
width of the occlusal surface of the impacted mandibular third molar and wider than 1/2;
and (6) Class III, when the distance from the anterior margin of the ascending mandibular
ramus to the distal surface of the mandibular second molar is narrower than the width of
the occlusal surface of the impacted mandibular third molar (Figure 1).
 Appl. Sci. 2021, 11, 816
terior margin of the ascending mandibular ramus to the distal surface of the mandibular 3 of 18

second molar is narrower than the width of the occlusal surface of the impacted mandib-
ular third molar and wider than 1/2; and (6) Class III, when the distance from the anterior
margin of the face of the impacted
ascending mandibular mandibular third
ramus to the molar;
distal (5) Class
surface of theII,mandibular
when the distance
second from the an-
teriorthan
Appl. Sci. 2021, 11, 816molar is narrower margin of the of
the width ascending mandibular
the occlusal surface oframus to the distal
the impacted surface third
mandibular of the mandibular
3 of 16
molar (Figuresecond
1). molar is narrower than the width of the occlusal surface of the impacted mandib-
ular third molar and wider than 1/2; and (6) Class III, when the distance from the anterior
margin of the ascending mandibular ramus to the distal surface of the mandibular second
molar is narrower than the width of the occlusal surface of the impacted mandibular third
molar (Figure 1).

Figure 1. Pell and Gregory

Figure classification:
1. Pell and (A) Class A, (A)
Gregory classification: (B) Class
Class A,
B, (C)
(B) Class
Class C, (D) Class
B, (C) Class C,
I, (E)
(D)Class
ClassII,I, and (F) Class III.
(E) Class
II, and (F) Class III.
2.1.2. Winter’s Classification
2.1.2. Winter’s Classification
Winter’s classification is based on the angle of impaction of the mandibular third
Figure
Winter’smolar 1. Pell and
classification is Gregory
based on classification:
theisangle (A) Class A, (B)of
of impaction Class
theofB,mandibular
(C) Class C, (D) Class I, (E) Class
third
[34]. The reference angle the angle to the long axis the mandibular second molars.
II, and
molar [34]. The (F) Class
reference III. is the angle ◦to the ◦long axis of the mandibular
angle second
◦ ◦
It was classified into vertical (10 –−10 ), mesioangular (11 –79 ), horizontal (80◦ –100◦ ),
molars. It was classified into
distoangular (−11vertical
◦ –−79◦(10°–−10°),
), transversemesioangular (11°–79°),
(buccal–lingual), horizontal
and inverted (101◦(80°–
–−80◦ ) (Figure 2).
2.1.2. Winter’s
100°), distoangular (−11°–−79°),Classification
transverse (buccal–lingual), and inverted (101°–−80°)
(Figure 2).

Figure 2. Winter’s classification.

2.2. Panoramic
Figure Radiograph
2. Winter’s classification.
The relationship between the IAN and the mandibular third molar root was observed
2.2.panoramic
on Panoramic radiography.
Radiograph Based on seven radiographic signs suggested by Rood and
Shehab The relationship between
[20], darkening the
and bifid ofIAN and apex
the root the mandibular
at the IAN third molar
area was root was
included as observed
the case
ondarkening
of panoramicofradiography. Based
the root because on seven
it was radiographic
not easy signs In
to distinguish. suggested
addition,bythere
Rood and
were
cases where the dark line is visible at the root apex, and this case was also investigated.
The radiographic signs were divided into a total of seven observations (Figures 3 and 4):
 The relationship between the IAN and the mandibular third molar root was observed
on panoramic radiography. Based on seven radiographic signs suggested by Rood and
Shehab [20], darkening and bifid of the root apex at the IAN area was included as the case
of darkening of the root because it was not easy to distinguish. In addition, there were
Appl. Sci. 2021, 11, 816 4 of 16
cases where the dark line is visible at the root apex, and this case was also investigated.
The radiographic signs were divided into a total of seven observations (Figures 3 and 4):
(1) cases where the root was darkened in the IAN area, (2) cases where the root was curved
at
(1)the IAN
cases area,the
where (3) root
cases where
was the root
darkened wasIAN
in the narrowed
area, (2)incases
the IAN
wherearea, (4) cases
the root with a
was curved
dark
at theline
IAN at area,
the root
(3) apex,
cases (5) cases
where with
the rootthe
wasloss of the white
narrowed line
in the of the
IAN IAN
area, (4) at the with
cases root
area,
a dark(6)line
cases with
at the roota narrowed IAN with
apex, (5) cases at thethe
root area,
loss andwhite
of the (7) cases with
line of theaIAN
change inroot
at the the
pathway of the with
area, (6) cases IAN aatnarrowed
the root area.
IAN at the root area, and (7) cases with a change in the
pathway of the IAN at the root area.

Appl. Sci. 2021, 3.

Figure 11,Rood
816 and Shehab classification of radiographic signs: (A) root darkening, (B) root deflection, (C) root narrowing,
5 of 18
Figure 3. Rood
(D) dark line inand Shehab
apex, classification
(E) loss of radiographic
of white line, signs: (A)
(F) inferior alveolar root(IAN)
nerve darkening, (B) root
narrowing, anddeflection, (C) root narrowing,
(G) IAN diversion.
(D) dark line in apex, (E) loss of white line, (F) inferior alveolar nerve (IAN) narrowing, and (G) IAN diversion.

Panoramicview.
Figure4.4.Panoramic
Figure view. Arrows
Arrows indicated the panoramic
panoramicsigns:
signs:(A)
(A)root
rootdarkening,
darkening,(B)
(B)root
rootdeflection,
deflection,(C)
(C)root narrowing,
root narrow-
ing,
(D) (D)
darkdark
line line in apex,
in apex, (E) loss
(E) loss of white
of white line,line, (F) inferior
(F) inferior alveolar
alveolar nervenerve (IAN)
(IAN) narrowing,
narrowing, and and (G) IAN
(G) IAN diversion.
diversion.

2.3. CBCT Analysis

2.3. CBCT Analysis
The positional relationship between the root of the mandibular third molar and the
The positional relationship between the root of the mandibular third molar and the in-
inferior alveolar nerve was analyzed. In the panoramic radiograph, the root of the man-
ferior alveolar nerve was analyzed. In the panoramic radiograph, the root of the mandibular
dibular third molar and the inferior alveolar nerve overlapped, but CBCT was observed
third molar and the inferior alveolar nerve overlapped, but CBCT was observed to see if they
to see if they were actually in contact with each other, and whether they were on the buccal
side, on the lingual side, below the root, or between the root if not on the bucco–lingual
side (Figure 5). In addition, the relationship between the root of the mandibular third mo-
lar and the lingual cortical bone was also observed. If continuity of the lingual cortical
bone was lost due to the root, it was classified as cortical bone perforation. Finally, patients
 Figure 4. Panoramic view. Arrows indicated the panoramic signs: (A) root darkening, (B) root deflection, (C) root narrow-
ing, (D) dark line in apex, (E) loss of white line, (F) inferior alveolar nerve (IAN) narrowing, and (G) IAN diversion.

2.3. CBCT Analysis

The positional relationship between the root of the mandibular third molar and the
Appl. Sci. 2021, 11, 816 5 of 16
inferior alveolar nerve was analyzed. In the panoramic radiograph, the root of the man-
dibular third molar and the inferior alveolar nerve overlapped, but CBCT was observed
to see if they were actually in contact with each other, and whether they were on the buccal
side, on
were the lingual
actually side,with
in contact beloweach the root,and
other, or between
whether thetheyroot
wereif on
notthe
on buccal
the bucco–lingual
side, on the
side (Figure
lingual side, 5). In addition,
below the root, the relationship
or between between
the root if notthe
on root of the mandibular
the bucco–lingual third mo-
side (Figure 5).
lar and the the
In addition, lingual cortical between
relationship bone was thealso
rootobserved. If continuity
of the mandibular thirdof the lingual
molar and the cortical
lingual
bone was
cortical lostwas
bone duealso
to the root, it was
observed. classifiedofasthe
If continuity cortical bone
lingual perforation.
cortical bone wasFinally, patients
lost due to the
who
root, complained of nerve
it was classified injury
as cortical afterperforation.
bone surgical extraction were investigated
Finally, patients using of
who complained medical
nerve
records.
injury after surgical extraction were investigated using medical records.

Figure 5. Relationship
Figure 5. Relationship between the inferior alveolar canal and roots
roots in
in cone
cone beam
beam computer
computer tomography
tomography views:
views: (A) root
darkening in panoramic
panoramicview,
view,(B)
(B)root
rootdeflection
deflectioninin
panoramic
panoramicview, (C)(C)
view, root narrowing
root in panoramic
narrowing in panoramicview, (D) (D)
view, darkdark
line
in apex
line in panoramic
in apex view,view,
in panoramic (E) loss
(E)ofloss
white line inline
of white panoramic view, (F)
in panoramic inferior
view, alveolaralveolar
(F) inferior nerve (IAN)
nervenarrowing in pano-
(IAN) narrowing
ramic
in view, and
panoramic (G)and
view, IAN diversion
(G) in panoramic
IAN diversion view. view.
in panoramic

2.4. Statistical Analysis

2.4. Statistical Analysis
Statistical analysis of this study was performed using the SPSS 20.0 (SPSS Software,
Statistical
Chicago, analysis
IL, USA) of this
statistical study was
program. Theperformed using
frequency and the SPSS of
percentage 20.0 (SPSS
each Software,
category was
Chicago, IL, USA) statistical program. The frequency and percentage of each category
was calculated, and the chi-square test was performed for categorical variables. The correc-
tion odds ratio was obtained for each category and verified and analyzed at the significance
level p < 0.05.

3. Results
3.1. Distributions of Gender and Age
The average age was 33.5 years, and 10- to 39-year-olds accounted for 88.4%. The age
distribution was 16.6%, 56.9%, and 14.9% in the second, third, and fourth decades of life,
respectively (Table 1). A total of 4708 of 6182 people underwent third molar extraction;
men were 52.1% and 47.9% were women.

3.2. Impaction Patterns

Horizontal impaction (42.1%) was the most common, followed by mesial impaction
(29.8%), vertical impaction (22.9%), inverted impaction (2.7%), distoangular impaction
(1.5%), and bucco–lingual transverse impaction (0.9%) (Figure 6).

3.3. Impaction Depth

In the Pell and Gregory classification, class A (53.4%) was the most common, followed
by class B (34%), and class C (12.6%). For Class I, II, and III classification, Class II (55.3%)
was the most common, followed by Class III (33.0%) and Class I (11.7%). When the two
categories were combined and confirmed, Class IIA (30%) occupied the largest proportion,
followed by Class IIB (19%), Class IIIA (16%), and Class IIIB (12%) (Table 2).
 men were 52.1% and 47.9% were women.

Table 1. Distributions of gender and age.

No. %
Appl. Sci. 2021, 11, 816 6 of 16
Total 6182 100.0
Male 3220 52.1
Gender
Female 2962 47.9
Table 1. Distributions of gender and age.
10–19 1026 16.6
No. %
20–29 3518 56.9
Total 6182 100.0
30–39 921 14.9
Age Male40–49 3220
436 7.1 52.1
Gender
Female 2962 47.9
50–59 178 2.9
10–1960–69 102675 1.2 16.6
20–29 3518 56.9
70~ 28 0.4
30–39 921 14.9
Age 40–49 436 7.1
3.2. Impaction Patterns 50–59 178 2.9
60–69
Horizontal impaction (42.1%) was the most common,75followed by mesial impaction
1.2
70~ inverted impaction 28
(29.8%), vertical impaction (22.9%), 0.4
(2.7%), distoangular impaction
(1.5%), and bucco–lingual transverse impaction (0.9%) (Figure 6).

50

40

30

20

10

0
Horizontal Mesioangular Vertical Inverted Distoangular Transverse

Figure 6. Distribution of the Winter classification: horizontal impaction (42.1%), mesioangular impaction (29.8%), vertical
Figure 6. Distribution of the Winter classification: horizontal impaction (42.1%), mesioangular impaction (29.8%),
impaction (22.9%), inverted impaction (2.7%), distoangular impaction (1.5%), and transverse impaction (0.9%).
vertical impaction (22.9%), inverted impaction (2.7%), distoangular impaction (1.5%), and transverse impaction (0.9%).
3.3. Impaction Depth
Table 2. In the Pell and
Distribution Gregory
of the classification,
Pell and class A (53.4%) was the most common, fol-
Gregory classification.
lowed by class B (34%), and class C (12.6%). For Class I, II, and III classification, Class II
(55.3%) was the most common, followed by Class III (33.0%) No. and Class I (11.7%).% When
Total 10,310 100.0
A 5509 53.4
P.G. A, B, C B 3503 34.0
C 1298 12.6
I 1204 11.7
P.G. I, II, III II 5704 55.3
III 3402 33.0
IA 756 7.3
IB 320 3.1
IC 128 1.2
IIA 3088 30.0
P.G. A, B, C and I, II, III IIB 1990 19.3
IIC 626 6.1
IIIA 1665 16.1
IIIB 1193 11.6
IIIC 544 5.3

Age and Pell and Gregory classification (P.G.) showed a statistically significant corre-
lation as a result of Pearson’s chi-square test, with a significance less than 0.05 (Table 3).
Appl. Sci. 2021, 11, 816 7 of 16

Table 3. Age distribution of the Pell and Gregory classification.

Age A (%) B (%) C (%) Total (%) p Value Age I (%) II (%) III (%) Total (%) p Value
1243 459 177 1879 173 1034 672 1879
10–19 10–19
(66.2) (24.4) (9.4) (100.0) (9.2) (55.0) (35.8) (100.0)
3424 2157 481 6062 646 3395 2021 6062
20–29Appl. Sci. 2021, 11, 816 20–29 8 of 18
(56.5) (35.6) (7.9) (100.0) (10.7) (56.0) (33.3) (100.0)
554 549 290 1393 177 773 44. 1393
30–39 30–39
(39.8) (39.4) (20.8) (100.0) (12.7) (55.5) (31.8) (100.0)
174 242 204 Table620 3. Age distribution of the Pell and Gregory
103 classification.
345 172 620
40–49 40–49
Age(28.1)A (%) (39.0) B (%) (32.9) C (%) (100.0) p
Total (%) < 0.001 *
p Value Age (16.6)
I (%) (55.6)
II (%) (27.7)
III (%) (100.0)
Total (%) p < 0.001 *
p Value
66 63 96 225 50 107 68 225
50–5910–19 1243 (66.2) 459 (24.4) 177 (9.4) 1879 (100.0) 10–19 173 (9.2) 1034 (55.0) 672 (35.8) 1879 (100.0)
50–59
(29.3) (28.0) (42.7) (100.0)
20–29 3424 (56.5) 2157 (35.6) 481 (7.9) 6062 (100.0)
(22.2) (47.6) (30.2) (100.0)
20–29 646 (10.7) 3395 (56.0) 2021 (33.3) 6062 (100.0)
39 27 32 40 36 22
60–6930–39 554 (39.8) 549 (39.4) 290 (20.8) 1393 (100.0)
33 (100.0) 30–39 177 (12.7) 773 (55.5) 44. (31.8) 139333
60–69 (100.0)
(100.0)
(39.8) (27.6) (32.7) (40.8) (36.7) (22.4)
40–49 174 (28.1) 242 (39.0) 204 (32.9) 620 (100.0) 40–49 103 (16.6) 345 (55.6) 172 (27.7) 620 (100.0)
9 6 18 p < 0.001 * 15 14 p < 0.001 *
70–7950–59 66 (29.3) 63 (28.0) 96 (42.7) 33 (100.0)
225 (100.0) 70–79 4 (12.1) 225 33
50–59 50 (22.2) 107 (47.6) 68 (30.2) (100.0)
(100.0)
(27.3) (18.1) (54.5) (54.5) (42.4)
60–69 39 (39.8) 27 (27.6) 32 (32.7) 33 (100.0) 60–69 40 (40.8) 36 (36.7) 22 (22.4) 33 (100.0)
5509 3503 1298 10,310 1204 5704 3402 10,310
Total 70–79 9 (27.3) 6 (18.1) 18 (54.5) 33 (100.0) Total
70–79 15 (54.5) 14 (42.4) 4 (12.1) 33 (100.0)
(53.4) (34.0) (12.6) (100.0) (11.7) (55.3) (33.0) (100.0)
Total 5509 (53.4) 3503 (34.0) 1298 (12.6) 10,310 (100.0) Total 1204 (11.7) 5704 (55.3) 3402 (33.0) 10,310 (100.0)
** Statistical significancepp<<0.05,
Statisticalsignificance 0.05,Pearson’s
Pearson’schi-square
chi-squaretest.
test.

3.4.3.4. Relationshipbetween
Relationship betweenthe
theIAN
IAN and
and the
theMandibular
Mandibular Third Molar
Third in Panorama
Molar in Panorama
A total of 88.7% were in contact with the IAN in panoramic view. As for the signs
A total of 88.7% were in contact with the IAN in panoramic view. As for the signs that
that could infer the relationship between the IAN and the mandibular third molar, root
could infer the relationship between the IAN and the mandibular third molar, root darkening
darkening cases (30.2%) of the IAN region showed the largest number, and the second
cases (30.2%) of the IANofregion
was the interruption showed
the IAN (24.7%)thewhere
largest
thenumber, and
white line ofthe
thesecond
inferiorwas the interruption
alveolar nerve
of the IAN (24.7%) where the white line of the inferior alveolar nerve canal was
canal was absent from the teeth, followed by a dark line of the root (16.2%), deflection absent
of from
the the
teeth,
rootfollowed by a darkofline
(9.6%), diversion the of the(5.1%)
IAN root (16.2%), deflection
root narrowing of the
(5.0%), root
and (9.6%), diversion
narrowing of the of
the IAN
IAN(3.7%)
(5.1%)(Figure
root narrowing
7). (5.0%), and narrowing of the IAN (3.7%) (Figure 7).

35

30

25

20

15

10

0
Root Interruption Dark line of Root IAN Root IAN
Darkening of IAN Root Deflection Diversion Narrowing Narrowing

7. Distributions
FigureFigure of panoramic
7. Distributions signs:signs:
of panoramic root darkening (30.2%),
root darkening interruption
(30.2%), of the
interruption inferior
of the alveolar
inferior nerve
alveolar (IAN)
nerve (24.7%),
(IAN)
(24.7%),
dark line of thedark
rootline of theroot
(16.2%), rootdeflection
(16.2%), root deflection
(9.6%), (9.6%), IAN
IAN diversion diversion
(5.1%), root(5.1%), root narrowing
narrowing (5.0%), and(5.0%), and IAN Nar-
IAN Narrowing (3.7%).
rowing (3.7%).

3.5.3.5. Relationshipbetween
Relationship betweenthe
theIAN
IAN and
and the
theMandibular
Mandibular Third Molar
Third in CBCT
Molar in CBCT
In CBCT,
In CBCT, 6283cases
6283 cases(61%)
(61%) of
of the
theinferior
inferioralveolar
alveolarnerve were
nerve actually
were in contact
actually with with
in contact
thethe root
root of of
thethe mandibularthird
mandibular third molar,
molar, which
whichwaswasless than
less thatthat
than in the casecase
in the of panoramic
of panoramic
contact. Most often, the inferior alveolar nerve was located below the root of the mandib-
ular third molar (60%). The second most frequent case of the inferior alveolar nerve was
driving to the buccal side of the mandibular third molar (28%), driving to the lingual side
(10%), and driving between the open roots (1%), followed by driving between the closed
Appl. Sci. 2021, 11, 816 8 of 16

contact. Most often, the inferior alveolar nerve was located below the root of the mandibular
third molar (60%). The second most frequent case of the inferior alveolar nerve was driving
to the buccal side of the mandibular third molar (28%), driving to the lingual side (10%),
and driving between the open roots (1%), followed by driving between the closed roots
(0.4%). There were 10% of cases of the inferior alveolar nerve that appeared to be narrowed
due to the roots (Table 4).
It was found that there was a correlation between Pell and Gregory classification and the
actual contact between the inferior alveolar nerve and the third molar in CBCT. In Class A,
52.4% were in contact with the inferior alveolar nerve and the third molar in CBCT, 69.4%
in Class B, and 74.3% in Class C. In Class I, 46.9% were in contact with the inferior alveolar
nerve and the third molar in CBCT; in Class II, 58.2%; and in Class III, 70.4% (Table 5).

Table 4. Distribution of inferior alveolar nerve (IAN) pathway in cone beam computed
tomography (CBCT).

No. %
Contact 6283 60.9
Inferior pathway 6185 60.0
Buccal pathway 2931 28.4
Lingual pathway 1011 9.8
Inter-root pathway 144 1.4
Intra-root pathway 39 0.4
Narrowing canal 1033 10.0

Table 5. Association between the Pell and Gregory classification and contact in cone beam computed tomography (CBCT).

P.G. Computed Without CT

tomography CT P.G. I, Without CT
A, B,
(CT) Contact Contact Total (%) p Value II, III Contact
Contact (%) Total (%) p Value
C (%)
(%) (%)
A 2889 (52.4) 2620 (47.6) 5509 (100.0) I 565 (46.9) 639 (53.1) 1204 (100.0)
B 2430 (69.4) 1073 (30.6) 3503 (100.0) p < 0.001 * II 3322 (58.2) 2382 (41.8) 5704 (100.0) p < 0.001 *
C 964 (74.3) 334 (25.7) 1298 (100.0) III 2396 (70.4) 1006 (29.6) 3402 (100.0)
Total 6283 (60.9) 4027 (39.1) 10,310 (100.0) Total 6283 (60.9) 4027 (39.1) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

In addition, there was a correlation between the Pell and Gregory classification and
CBCT when the inferior alveolar nerve was in contact with the third molar root and the
inferior alveolar nerve was narrowed. In Class A, 52.4% were in contact with the inferior
alveolar nerve and the mandibular third molar in CBCT, 69.4% in Class B, and 74.3%
in Class C. In Class I, 46.9% were in contact with the inferior alveolar nerve and the
mandibular third molar in CBCT, 58.2% in Class II, and 70.4% in Class III (Table 6).

Table 6. Association between the Pell and Gregory classification and the narrowing canal in cone beam computed
tomography (CBCT).

P.G. A, Narrowing Without P.G. I, Narrowing Without

B, C Canal (%) Narrowing Total (%) p Value II, III Canal (%) Narrowing Total (%) p Value
Canal (%) Canal (%)
A 396 (7.2) 5113 (92.8) 5509 (100.0) I 69 (5.7) 1135 (94.3) 1204 (100.0)
B 444 (12.7) 3059 (87.3) 3503 (100.0) p < 0.001 * II 497 (8.7) 5207 (91.3) 5704 (100.0) p < 0.001 *
C 193 (14.9) 1105 (85.1) 1298 (100.0) III 467 (13.7) 2935 (86.3) 3402 (100.0)
Total 1033 (10.0) 9277 (90.0) 10,310 (100.0) Total 1033 (10.0) 9277 (90.0) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

The correlation between the panoramic signs and the actual inferior alveolar nerve
contact with the mandibular third molar was investigated using CBCT. Root darkening
(p < 0.001 *), root deflection (p < 0.001 *), interruption of the IAN (p < 0.001 *), diversion
of the IAN (p < 0.001 *), narrowing of the IAN (p < 0.001 *), and five other signs were ana-
lyzed as having significant correlations (Table 7).
Appl. Sci. 2021, 11, 816 9 of 16

The case where the continuity of the lingual cortical bone disappeared due to the root
of the mandibular third molar was investigated in 13.9%. A dark line at the root apex
in panoramic radiography showed a correlation with lingual cortical bone fenestration
in CBCT (Table 8).

3.6. Second and Third Molar Pathology

The pathological condition of the second and third molars was investigated by exam-
ining the medical records and panoramic radiography. 7.3% was found with pericoronitis
around the third molar, and 5.2% had dental caries on the proximal surface of the second
molar. In addition, there was 1.4% of root resorption of the second molars, and 1.3% of cys-
tic lesions of the third molars. There was a significant correlation between the incidence
of dental caries on the proximal surface of the second molars (Table 9) and the incidence
of pericoronitis of the mandibular third molar according to the impact angulation of the
third molars (Table 10).

3.7. Inferior Alveolar Nerve (IAN) Injury

Of the 4708 patients who underwent surgical extraction, 31 (0.658%) complained
of nerve damage. Among them, 30 patients complained of symptoms of IAN injury,
and 1 patient complained of symptoms of lingual nerve injury. In 30 patients with IAN
injury, they were administered 50 mg of vitamedin twice a day, 21.96 mg of adenosine
triphosphate disodium trihydrate twice a day for 2 weeks, and 30 mg of prednisolone once
daily for 12 days with a step down of 5 mg every 2 days. A total of 21 of 30 patients had
resolved the symptoms of nerve injury and 9 patients complained of persistent nerve injury.
The risk factors of IAN injury were analyzed with impaction pattern, panoramic signs,
and CBCT driving pathway except for lingual nerve injury caused by the anesthesia needle.
IAN injury was significantly correlated with gender and age (Tables 11 and 12).

Table 7. Association between panoramic signs and contact in cone beam computed tomography (CBCT).

CT Contact Without CT
Total (%) p Value
(%) Contact (%)
Root darkening 2334 (71.8) 876 (28.2) 3110 (100.0)
p < 0.001 *
Without root darkening 4049 (56.2) 3151 (43.8) 7200 (100.0)
Root deflection 664 (67.1) 325 (32.9) 989 (100.0)
p < 0.001 *
Without root deflection 5619 (60.3) 3702 (39.7) 9321 (100.0)
Root narrowing 332 (64.5) 183 (35.5) 515 (100.0)
p = 0.093
Without root narrowing 5951 (60.8) 3844 (39.2) 9795 (100.0)
Dark line of root 1021 (61.1) 651 (38.9) 1672 (100.0)
p = 0.910
Without dark line of root 5262 (60.9) 3376 (39.1) 8638 (100.0)
Interruption of IAN 1944 (76.3) 604 (23.7) 2548 (100.0)
p < 0.001 *
Without interruption of IAN 4339 (55.9) 3423 (44.1) 7762 (100.0)
IAN diversion 474 (89.6) 55 (10.4) 529 (100.0)
p < 0.001 *
Without IAN diversion 5809 (59.4) 3972 (40.6) 9781 (100.0)
IAN narrowing 319 (83.5) 63 (16.5) 382 (100.0)
p < 0.001 *
Without IAN narrowing 5964 (60.1) 3964 (39.9) 9928 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

Table 8. Association between a dark line of root in panoramic view and lingual cortical bone
fenestration in cone beam computed tomography (CBCT).

Lingual Cortical Bone No Lingual Bone

Total (%) p Value
Fenestration (%) Fenestration (%)
Dark line of root 796 (47.6) 876 (52.4) 1672 (100.0)
Without dark
634 (7.3) 8004 (92.7) 8638 (100.0) p < 0.001 *
line of root
Total 1430 (13.9) 8880 (86.1) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.
Appl. Sci. 2021, 11, 816 10 of 16

Table 9. Association between impaction angulation and proximal caries of the second molar.

Proximal Caries Without Proximal

of Second Caries of Second Total (%) p Value
Molar (%) Molar (%)
Horizontal impaction 195 (4.5) 4148 (95.5) 4343 (100.0)
Mesioangular impaction 251 (8.2) 2824 (91.8) 3075 (100.0)
Vertical impaction 75 (3.2) 2290 (96.8) 2365 (100.0)
Distoangular impaction 5 (3.2) 153 (96.8) 158 (100.0) p < 0.001 *
Inverted impaction 9 (3.2) 271 (96.8) 280 (100.0)
Transverse impaction 0 (0.0) 89 (100.0) 89 (100.0)
Total 535 (5.2) 9775 (94.8) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

Table 10. Association between impaction angulation and pericoronitis.

Without
Pericoronitis (%) Total (%) p Value
Pericoronitis (%)
Horizontal impaction 297 (6.8) 4046 (93.2) 4343 (100.0)
Mesioangular impaction 175 (5.7) 2900 (94.3) 3075 (100.0)
Vertical impaction 189 (8.0) 2176 (92.0) 2365 (100.0)
Distoangular impaction 38 (24.1) 120 (75.9) 158 (100.0) p < 0.001 *
Inverted impaction 49 (17.5) 231 (82.5) 280 (100.0)
Transverse impaction 6 (6.7) 83 (93.3) 89 (100.0)
Total 754 (7.3) 9556 (92.7) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

In the Pell and Gregory classification, Classes A, B, and C were found to be correlated
with nerve injury, and Classes I, II, and III were not correlated (Table 13).
There was a significant correlation with inferior alveolar nerve injury in cases where
the roots became dark at the IAN area (p = 0.018) and diversion of the inferior alveolar
nerve at the root area (p = 0.041) (Table 14).
Finally, there was no significant correlation between the driving pathway of the IAN
and the IAN injury in CBCT. However, when the IAN showed a lingual pathway and
narrowing at the same time, there was a significant correlation with IAN injury (Table 15).

Table 11. Association between gender and numbness.

Gender Numbness (%) Without Numbness (%) Total (%) p Value

Male 10 (0.2) 5374 (99.8) 5384 (100.0)
Female 20 (0.4) 4906 (99.6) 4926 (100.0) p = 0.038 *
Total 30 (0.3) 10,280 (99.7) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

Table 12. Association between age and numbness.

Age Numbness (%) Without Numbness (%) Total (%) p Value

10–19 0 (0.0) 1879 (100.0) 1879 (100.0)
20–29 16 (0.3) 6046 (99.7) 6062 (100.0)
30–39 6 (0.4) 1387 (99.6) 1393 (100.0)
40–49 4 (0.6) 616 (99.4) 620 (100.0)
50–59 4 (1.8) 221 (98.2) 225 (100.0) p < 0.001 *
60–69 0 (0.0) 98 (100.0) 98 (100.0)
70–79 0 (0.0) 30 (100.0) 30 (100.0)
80 0 (0.0) 3 (100.0) 3 (100.0)
Total 30 (0.3) 10,280 (99.7) 1031 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.
Appl. Sci. 2021, 11, 816 11 of 16

Table 13. Association between the Pell and Gregory classification (P.G.) and numbness.

P.G.A, Numbness Without P.G. I, Numbness Without

B, C (%) Numbness Total (%) p Value II, III (%) Numbness (%) Total (%) p Value
(%)
A 7 (0.1) 5502 (99.9) 5509 (100.0) I 1 (0.1) 1203 (99.9) 1204 (100.0)
B 16 (0.5) 3487 (99.5) 3503 (100.0) p = 0.004 * II 21 (0.4) 5683 (99.6) 5704 (100.0) p = 0.189
C 7 (0.5) 1291 (99.5) 1298 (100.0) III 8 (0.2) 3394 (99.8) 3402 (100.0)
Total 30 (0.3) 10,280 (99.7) 10,310 (100.0) Total 30 (0.3) 10,280 (99.7) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

Table 14. Association between panoramic signs and inferior alveolar nerve (IAN) injury.

Nerve Without
Total (%) p Value
Injury (%) Injury (%)
Root darkening 15 (0.5) 3095 (99.5) 3110 (100.0)
p = 0.018 *
Without root darkening 15 (0.2) 7185 (99.8) 7200 (100.0)
Root deflection 4 (0.4) 985 (99.6) 989 (100.0)
p = 0.486
Without root deflection 26 (0.3) 9295 (99.7) 9321 (100.0)
Root narrowing 3 (0.6) 512 (99.4) 515 (100.0)
p = 0.208
Without root narrowing 27 (0.3) 9768 (99.7) 9795 (100.0)
Dark line of root 2 (0.1) 1670 (99.9) 1672 (100.0)
p = 0.155
Without dark line of root 28 (0.3) 8610 (99.7) 8638 (100.0)
Interruption of IAN 9 (0.4) 2539 (99.6) 2548 (100.0)
p = 0.501
Without interruption of IAN 21 (0.3) 7741 (99.7) 7762 (100.0)
IAN diversion 4 (0.8) 525 (99.2) 529 (100.0)
p = 0.041 *
Without IAN diversion 26 (0.3) 9755 (99.7) 9781 (100.0)
IAN narrowing 1 (0.3) 381 (99.7) 382 (100.0)
p = 0.914
Without IAN narrowing 29 (0.3) 9899 (99.7) 9928 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

Table 15. Risk factors of inferior alveolar nerve (IAN) injury in cone beam computed
tomography (CBCT).

Risk Factors Injury (%) Without Injury (%) Total (%) p Value
Both lingual pathway
24 (3.8) 605 (96.0) 629 (100.0)
and IAN narrowing
Only lingual pathway 0 (0.0) 592 (100.0) 592 (100.0)
p < 0.001 *
Only IAN narrowing 3 (0.0) 8682 (100.0) 8685 (100.0)
No lingual pathway or
3 (0.7) 401 (99.3) 404 (100.0)
IAN narrowing
Total 30 (0.3) 10,280 (99.7) 10,310 (100.0)
* Statistical significance p < 0.05, Pearson’s chi-square test.

4. Discussion
Extraction of the mandibular third molar is the most commonly performed surgical
procedure in oral and maxillofacial surgery. IAN injury can cause a lot of discomfort to the
patient and lower the quality of life [35]. However, there are still not many studies on the
relationship between the inferior alveolar nerve and mandibular third molars in populations.
This study was to evaluate the pattern of mandibular third molar impaction in Korea
and to evaluate the risk factors of inferior alveolar nerve damage that may occur during
extraction. Prevalence of third molar impaction is reported to range from 30.3% to 68.6% [2–6].
The prevalence of impaction could not be determined in this study as it was intended for
patients with impacted mandibular third molars. The gender difference regarding the impacted
mandibular third molar varied from study to study. Previous studies showed that women
have a higher prevalence of impaction [6,36] and another study showed that men have a higher
prevalence of impaction [37]. Impaction of the third molar was 52.1% in men, and the average
age was 33.5 years. Patients 10 to 39 years old accounted for 88.4% of this study.
The impaction pattern was varied according to the angulation. Most of studies showed
that mesial angulation [6,38–41] and vertical impaction [42,43] occur frequently. In this
Appl. Sci. 2021, 11, 816 12 of 16

study, horizontal angulation was most popular. CBCT is taken when there is a suspi-
cion of contact between the IAN and the mandibular third molar in panoramic radio-
graphs, or when the third molars are completely impacted. Since the subject of this study
was patients who underwent CBCT, this might have affected the outcome as patients with
a mandibular third molar impacted by a vertical or a mesial impaction, which is relatively
far from the IAN, were not included.
According to the Pell and Gregory classification, the most prevalent was Class IIA
(30.0%), followed by Class IIB (19.3%). This is consistent with previous results [1,14,44].
Monaco [45] reported that Class A (56.2%) and Class II (63%) were the most common among
Italians, and Blondeau [46] and Almendros-Marques [43] reported that Class IIB was the
most common. It can be seen that Koreans do not differ in the degree and distribution of
impaction from different races. In addition, it was found that the depth of the impaction
increased as age increased. This suggests that patients with low impacted mandibular third
molars remove their teeth at a relatively young age, so as the age increases, deep impacted
mandibular third molars, which are difficult to extract, are present at a higher rate.
Panoramic radiographic signs were reported to occur at a low frequency of 0.1%~3.3%
in the study by Rood and Shehab [20]. Sedaghatfar et al. [11] reported the occurrence
at a rate of 11.8–35.9%, similar to this study. This difference is thought to be due to the
difference between observers in determining the symptoms, as the evaluation of the signs
in the panoramic radiograph is not standardized. In addition, the subjects of this study
had panoramic radiographs of the mandibular third molar and inferior alveolar nerves
that were in contact with each other, so it is thought that the incidence of signs was higher
than that of a completely randomized study.
In CBCT, the contact between the mandibular third molar and the inferior alveolar
nerve was observed in 61%, which was less than the cases with contact on the panoramic
radiograph (88.67%). This means that it was not possible to accurately determine whether
the mandibular third molar and the inferior alveolar nerve were actually in contact with the
panoramic radiograph. There was a significant correlation between the Pell and Gregory
classification, the contact between the mandibular third molar and the IAN in CBCT, and
the narrowing of the IAN in CBCT. This means that the deeper the degree of impaction of
the mandibular third molar, the closer it was to the IAN. As for the signs on the panoramic
radiograph, there was a correlation between the actual contact between the mandibular
third molar and the IAN in CBCT, except when the root was narrowed and there was a dark
line at the root apex [47–49].
There was a correlation between the disappearance of the continuity of the lingual
cortical bone at the root of the mandibular third molar and the dark line at the root apex.
Dark lines were observed in 55.7% of cases with lingual cortical bone perforation, and were
absent in 44.3% of cases with lingual cortical bone perforation. In the literature examining
the dark area of the root and lingual cortical bone perforation, it was suggested that the dark
area showed proximity to the IAN rather than the lingual cortical bone perforation [50].
It is believed that this is caused by not distinguishing from dark lines when irradiating
the dark area. If the root is in the lingual cortical bone, it is thought that the presence of
the periodontal ligament in the dense cortical bone and the perforated area of the cortical
bone appear as dark lines. The possibility of root fracture occurring during extraction
increases, and the fractured root may fall into the submandibular space, so care should
be taken during extraction. It would be useful if we could predict the existence of roots in
the lingual cortical bone only with panoramic radiographs, not CBCT.
In the case of proximal dental caries 46.9% had mesial impaction and 36.4% had
horizontal impaction. This is consistent with other studies that stated that the mesial and
horizontal impaction of the third molar accounts for most of the proximal caries of the
second molar [51,52]. In addition, when examining the relationship between pericoroni-
tis and impaction angulation in various studies, it was reported that vertical impaction
was the most common, followed by mesial impaction, and bone loss was most observed in
mesial impaction [53,54]. In this study, horizontal impaction was the most common (39.4%),
Appl. Sci. 2021, 11, 816 13 of 16

followed by vertical impaction (25.0%) and mesial impaction (23.2%). Out of 158 distal
impactions, 38 cases had pericoronitis, showing a high morbidity rate of about 24%.
The incidence of IAN injury was 0.637%, which is similar to or lower than that
reported in other studies [9–15]. Of the 30 patients with IAN injury, there was a statistically
significant correlation with gender (p = 0.038), with risk of nerve damage being higher in
women than men. Other studies reported that there was no correlation between gender
and nerve injury [31], but many studies have reported that women have a higher risk of
nerve injury [23,24,55]. In addition, there was a significant correlation between age and
IAN injury. It can be seen that the possibility IAN injury increases with age. There was
also literature reporting that the age and risk of nerve injury were not correlated [55,56].
However, many studies have shown that the risk of IAN injury increases in those over
25 years of age, and age is a risk factor for nerve injury [15,23,57–61]. Age-related changes
such as a decrease in bone elasticity, an increase in the occurrence of hypercementosis, and
an increase in the amount of bone removal are thought to be the major causes of the increase
in the difficulty of surgery. There are studies suggesting a relationship between the depth of
impaction and the incidence of IAN injury [9,13,23,30,55,56,58,60], and a study suggesting
no relationship [31]. In the present study, it was found that there is a relationship between
the depth of impaction and the incidence of IAN injury. Naturally, the deeper the impaction
depth, the closer it is to the inferior alveolar nerve, and therefore, the probability of nerve
injury is thought to increase. No significant correlation was found between the signs of
panoramic radiographs and the incidence of IAN injury. This result is similar to most
studies [9,11,20,23,26,28,31]. It is considered that the prediction of IAN injury is inadequate,
as a panoramic radiograph sign has low sensitivity and high specificity. In this study,
among 30 patients with IAN injury, 24 showed that the IAN was driven to the lingual
side of the mandibular third molar root in CBCT, and at the same time, a narrowing of
the IAN was observed. When these two features are observed at the same time, it can
be said that the incidence of IAN injury increases. The narrowed IAN in CBCT and the
lingual pathway of the IAN is consistent with other studies that suggested increased risk of
IAN injury [27,32,62,63]. The narrowing of the IAN canal means that the distance between
the root of the mandibular third molar and the IAN canal is less. Clinically, when the
mandibular third molar is extracted, most of the instrumentation is performed on the buccal
side. Because of this, there are many cases where the tooth comes out while applying force
in the lingual direction. Due to this effect, it is thought that the lingual movement and
narrowing of the IAN cause IAN injury during extraction. This is thought to be a good
factor in predicting the occurrence of nerve injury.
This study examined the impaction pattern and the risk factors affecting injury to
the IAN in Koreans. The study had several limitations. First, it cannot be concluded that
the study reflects the overall characteristics of Koreans, as it was short-term research by
a single institution. Second, the study only included patients who underwent panoramic
radiography and CBCT, instead of using random target collection. Unlike other studies,
this study was intended for patients with impacted mandibular third molars and also for
patients who underwent CBCT, following a suspicion of an impacted third mandibular
molar being in contact with the inferior alveolar nerve. For this reason, there are limitations
to consider when interpreting the results; therefore, the study cannot be generalized to the
Korean population with impacted third mandibular molars. Third, the symptoms of patients
with an IAN injury could not be described in detail due to the incomplete medical records
and the loss of follow-up. As in other studies, it is necessary to classify the symptoms of
temporary and permanent nerve injury and investigate the intensity of the symptoms.
The data and results of this study can be used to set the direction of future research.
With more complementary studies, we can set the criteria for classification of the mandibu-
lar third molar in Koreans, analyze the third molar conveniently and quickly using artificial
intelligence, and further create programs that can determine the degree of difficulty in the
extraction, the possibility of injury to the IAN, and the possibility of complications.
Appl. Sci. 2021, 11, 816 14 of 16

5. Conclusions
In this study, Class IIA, IIB were dominant in the impaction pattern of the mandibular
third molar. In addition, when there was a dark line at the root apex on the panoramic
radiograph, it was found that the root of the mandibular third molar was often located
in the lingual cortical bone. It was found that when the narrowing of the IAN and the
lingual driving pathway of the IAN appeared simultaneously in CBCT, the risk of an IAN
injury was high. These two factors appear together, and clinicians should explain the
possibility of IAN injury to the patient and the need to extract more carefully.

Author Contributions: Conceptualization, S.Y.M.; methodology, S.Y.M.; software, S.Y.M. and H.J.K.
(Hyo Joon Kim); validation, S.Y.M., H.J.K. (Hee Jin Kim), and H.J.K. (Hyo Joon Kim); formal
analysis, S.Y.M. and H.J.K. (Hyo Joon Kim); investigation Y.J.J., J.S.C., H.J.K. (Hee Jin Kim) and
H.J.K. (Hyo Joon Kim); resources, S.Y.M.; data curation, S.Y.M., Y.J.J., J.S.C. and H.J.K. (Hee Jin Kim);
writing—original draft preparation, H.J.K. (Hee Jin Kim); writing—review and editing, H.J.K.
(Hee Jin Kim) and S.Y.M.; visualization, S.Y.M.; supervision, J.K. and S.Y.M.; project administra-
tion, S.Y.M.; funding acquisition, S.Y.M. All authors have read and agreed to the published version of
the manuscript.
Funding: This study was supported by the research fund from Chosun University, 2020.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Institutional Review Board of Chosun university dental
hospital (CUDHIRB 1902006R01).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing
is not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.

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