Dentomaxillofacial Radiology (2019) 48, 20190265

© 2019 The Authors. Published by the British Institute of Radiology

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Systematic Review
Panoramic versus CBCT used to reduce inferior alveolar nerve
paresthesia after third molar extractions: a systematic review
and meta-­analysis
1
Nathalia Calzavara Del Lhano, 2Rosangela Almeida Ribeiro, 3Carolina Castro Martins,
4
Neuza Maria Souza Picorelli Assis and 4Karina Lopes Devito
1
School of Dentistry, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; 2Department of Social and Pediatric
Dentistry, School of Dentistry, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; 3Department of Pediatric
Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil;
4
Department of Dental Clinic, School of Dentistry, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil

Objectives:  The aim of this systematic review was to verify whether CBCT in comparison
with panoramic radiography reduced the cases of temporary paresthesias of the inferior alve-
olar nerve (IAN) associated with third molar extractions.
Methods:  The literature search included five databases (PubMed, Scopus, Web of Science,
Cochrane, SciELO), in addition to gray literature and hand search of reference list of included
studies. Two reviewers independently screened titles/abstracts, and full texts according to eligi-
bility criteria, extracted data and evaluated risk of bias through Revised Cochrane Risk of
Bias Tool for Randomized Trials (RoB 2.0). Data were meta-­analyzed by comparing CBCT
versus panoramic radiographs for number of events (temporary paresthesia after third molar
surgery). Fixed effect model was used for non-­significant heterogeneity; relative risk (RR) and
95% CI were calculated. The certainty of evidence was evaluated by Grading of Recommenda-
tions, Assessment, Development, and Evaluation (GRADE).
Results:  Four randomized controlled trials (RCTs) were included in meta-­analysis, and for
the majority of domains they presented low risk of bias. RR was 1.23 (95% IC: 0.75–2.02;
I2: 0%; p = 0.43) favouring panoramic radiography, but without significant effect, and with
moderate certainty of evidence.
Conclusions:  We concluded that both interventions had a similar ability to reduce temporary
paresthesia of the IAN after third molar surgery with moderate certainty of evidence.
Dentomaxillofacial Radiology (2019) 48, 20190265. doi: 10.1259/dmfr.20190265

Cite this article as:  Del Lhano NC, Ribeiro RA, Martins CC, Assis NMSP, Devito KL. Pano-
ramic versus CBCT used to reduce inferior alveolar nerve paresthesia after third molar extrac-
tions: a systematic review and meta-­analysis. Dentomaxillofac Radiol 2019; 48: 20190265.

Keywords:  paresthesia; inferior alveolar nerve; third molar; CBCT; panoramic radiography

Introduction

Third molar extractions are some of the surgical proce-
dures most commonly performed by dental surgeons
and oral and maxillofacial specialists. As is the case
with any surgical procedure, this extraction may also be
associated with certain complications. One of the most
serious injuries that may occur during mandibular third
Correspondence to: Dr Karina Lopes Devito, E-mail: ​karina.​devito@​ufjf.​edu.​br
Received 07 July 2019; revised 03 October 2019; accepted 12 November 2019
molar removal is injury to the inferior alveolar nerve
(IAN), which may result in subsequent neurosensory
damage to the bottom lip and chin, with a negative
and significant impact on the quality of life of patients
affected.1
The mean risk of temporary lesion of the IAN asso-
ciated with third molar removal ranges from 0.4 to 6%.
The reported rate of permanent lesion of the IAN, in
 Panoramic X CBCT: paresthesia after third molar extractions
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which paresthesia lasts longer than 6 months, is lower
than 1%.2,3
Thus, it is important to evaluate the position of the
third molar and establish its relations with the mandib-
ular canal in the pre-­operative period, with the purpose
of minimizing risk of injury to the nerve. Panoramic
radiography, which provides only two-­dimensional infor-
mation, is the most usual diagnostic imaging modality
used for this purpose. Clinics use various radiographic
references for indicating the close relationship between
the third molar and mandibular canal: interruption of
one or both of the mandibular canal cortical bones;
darkening of the root; deviation of the mandibular
canal; abrupt dilaceration of the root; narrowing of the
root; darkening and divergence of the root apex; and
narrowing of the mandibular canal.4–6 Cases in which
the panoramic radiograph indicates a narrow relation-
ship between the third molar and mandibular canal,
an additional investigation may be recommended with
the use of CBCT to verify the relationship in a three-­
dimensional view without superimpositions.7–9
However, with the growing use of CBCT in dentistry,
and in many cases, involving third molar extractions, it
began to be the exam of first choice, at the expense of
panoramic radiography, without considering any ques-
tion about cost and radiation dose. Therefore, the real
advantages of using CBCT in third molar extraction
procedures have not yet been clearly established. There-
fore, the aim of this study was to conduct a systematic
review of the literature to help with decision-­making
about pre-­operative imaging that will reduce the chance
of temporary paresthesia of the IAN in cases of third
molar extractions.
Methods and materials
Protocol registration
The present systematic review was conducted in accor-
dance with the guidelines of Preferred Reporting Items
for Systematic Reviews and Meta-­Analyses (PRISMA)10
and was registered in the International Prospective
Register of Systematic Reviews (PROSPERO) code
number CRD42018108063.
PECO - Question
This systematic review was conducted with the purpose
of answering the following clinical question (PECO
question): “When CBCT is compared with panoramic
radiography, is it capable of reducing the number of
cases of temporary paresthesia of the IAN associated
with third molar extractions?”
Eligibility criteria
In this review, only clinical randomized controlled trials
(RCTs) were included, which had temporary pares-
thesia of the IAN as the only outcome, or as one of the
outcomes analysed. The primary studies included had
Dentomaxillofac
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Del Lhano et al
to allow comparison between panoramic radiography
and CBCT with regard to paresthesia. The following
were excluded: review, letters, case reports, other study
designs rather than RCTs, studies without the presence
of CBCT and panoramic radiography groups, and those
that did not fulfil the aim of the study.
Information sources and search
A detailed search of the literature was conducted in the
following electronic databases: PubMed, Scopus, Web of
Science, Cochrane and SciELO up to September 2018.
Articles were selected irrespective of year of publica-
tion and language. Sources of gray literature—Clinical
Trials, International Clinical Trials Registry Platform
(ICTRP) and Google Scholar—were also included.
A manual search of the reference lists of the included
studies was carried out for publications that were not
electronically identified.
The key words were divided into three groups,
according to the PECO question: population (P), expo-
sure (E) and outcome (O), including Medical Subject
Headings (MeSH) and non-­MeSH uniterms. Combina-
tions were made between them and the Boolean opera-
tors “AND” and “OR” (Figure 1).
All references were managed, and the duplicated
studies were removed using reference manager software
(Endnote Web, Thompson, Reuters, New York, NY).
Study selection
Two reviewers (KLD and NCDL) were calibrated for
application of the eligibility criteria described above.
To confirm the calibration, they thoroughly discussed
the criteria that was applied to a sample of 10% of the
retrieved studies to determine interexaminer agreement.
After adequate agreement was achieved (κ 0.73),11 titles
and abstracts of all studies were independently read by
both reviewers. The same authors applied the eligibility
criteria to the full-­text assessment of the selected arti-
cles. Disagreements about decisions were discussed and
resolved by consensus.
Data extraction
Data collection was also completed by two reviewers
(KLD and NCDL) independently. The following infor-
mation was recorded for all the included studies: A)
Study characteristics (author, year); B) Sample (size,
study groups; evaluation of the temporary paresthesia);
C) Findings (number of temporary paresthesia events,
comparison between the imaging modalities relative to
the outcome).
Quality assessment
The risk of bias was evaluated by using the Revised
Cochrane Risk of Bias Tool for Randomized Trials (RoB
2.0).12 This scale has five domains, and each of them
can be classified into: high risk of bias, some concerns
or low risk of bias. The domains included in this scale
are: bias arising from the randomization process, bias
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Figure 1  Key words used in the search strategy in the five databases used. Terms followed by asterisks (*) are MeSH terms.
due to deviations from intended interventions, bias due
to missing outcome data, bias in measurement of the
outcome and bias in selection of the reported result.
Meta-analysis
The software Review Manager (RevManager Version
5.3. Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014) was used to perform
the meta-­analysis. The data were summarized in abso-
lute numbers related to the number of cases with and
without temporary paresthesia, defined by neurosen-
sory tests for both groups: CBCT and panoramic radi-
ography. We also extracted the total sample of each
intervention. Statistical heterogeneity was calculated
by means of the I2 statistics. The Mantel-­Haenszel fixed
effect model was used when the statistical heterogeneity
was not significant (p > 0.05).13 The estimated effect
(relative risk, RR) was calculated for the occurrence of
temporary paresthesia in individuals with exposure to
(CBCT versus individuals without exposure panoramic
radiography).
Level of evidence
The certainty of evidence was evaluated by GRADE
by using the GRADEpro platform (McMaster Univer-
sity, Hamilton, Canada). RCTs start with high level of
evidence. We rated down one or two levels if there were
Panoramic X CBCT: paresthesia after third molar extractions
Del Lhano et al 3 of 8
problems of: risk of bias, inconsistency, imprecision,
indirectness and publication bias.14
Results
Selection of studies
A total of 780 records were identified in the electronic
databases searched: 154 in PubMed, 504 in Scopus, 107
in Web of Science, nine in Cochrane and six in Scielo.
No additional reference was obtained in the gray liter-
ature or manual search. After removing the duplicates,
563 studies were selected for title and abstract reading.
After reading the titles and abstracts, 484 studies were
excluded, thus 79 articles remained for complete text
reading. Of the 79 articles, four were included in the
qualitative and quantitative analyses (meta-­ analysis).
In Figure 2, the PRISMA diagram is presented, which
shows the selection of studies.
General characteristics of the studies
Four RCTs were included in the present systematic
review.15–18 Detailed information about the study groups,
evaluation of outcome, number of cases of paresthesia
and comparison between the imaging modalities for the
outcome temporary paresthesia are summarized in the
data extraction table (Table 1).
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Figure 2  PRISMA flow diagram summarizing the systematic review process in the identification of the studies included.
Quality evaluation
Figure 3 shows risk of bias of included studies. All the
articles presented “low risk of bias” for the majority of
domains evaluated. Two studies15,16 presented high risk
of bias in the domain with reference to the randomiza-
tion process, because they did not guarantee that allo-
cation of the participants in the groups was concealed.
Data synthesis and meta-analysis
Meta-­analysis showed that panoramic radiography
and CBCT had the similar effect on reducing pares-
thesia of the IAN in cases of third molar extractions
(RR: 1.23; 95% IC: 0.75–2.02; I2: 0%; p = 0.43)
(Figure 4).
GRADE
The certainty of the evidence of the comparison
between CBCT and the panoramic radiograph for the
occurrence of temporary paresthesia of the IAN was
moderate (Table 2).
Dentomaxillofac
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Del Lhano et al
Discussion
Temporary paresthesia of the IAN may occur as a compli-
cation of mandibular third molar extractions. Imaging
examinations are used for evaluating the position of the
tooth, number and morphology of the roots, and the
relationship between the tooth and mandibular canal.19–21
The examination most frequently used is panoramic radi-
ography, which shows the radiographic signs of the rela-
tionship of proximity between the mandibular canal and
third molar. When this close relationship is seen in the
panoramic radiograph, an additional investigation using
CBCT has been suggested. Because the CBCT is the most
accurate and sensitive imaging examination, it has been
considered capable of reducing the risk of interopera-
tive accidents, when compared with panoramic radiog-
raphy.7,22,23 Based on a previously taken panoramic image,
the studies analysed included mandibular third molars
with moderate risk of injury to the IAN,15,16 with regard
to the proximity to the mandibular canal17 and with
contact between or superimposition of the tooth and/or
the roots and the mandibular canal.18
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Table 1  Data Extraction

Study
Characteristics Sample Findings
Authors (Year) Total sample (n Groups of study Evaluation of temporary Temporary paraesthesia Comparison between
third molars) (n third molars) paraesthesia (7 days) (number of events) panoramic and CBCT for
the outcome
Guerrero et al.15 86 • Panoramic: Evaluation by Semmes • Panoramic Group: 1
There was no significant
n = 43 Weinstein monofilament (1.26%) difference between
• CBCT: n = 43 neurosensoric test • CBCT Group: 1 panoramic and CBCT
(1.26%) groups (lip: p = 0.10/
chin: p = 0.17)
Guerrero et al.16 256 • Panoramic: n = 130 Evaluation by Semmes • Panoramic Group: 5 There was no significant
• CBCT: n = 126 Weinstein monofilament (3.9%) difference between
neurosensoric test • CBCT Group: 2 panoramic and CBCT
(1.5%) groups (p = 0.45)
Ghaeminia et al.17 320 • Panoramic: n = 164 Objective evaluation: Objective evaluation: Objective evaluation:
• CBCT: n = 156 Evaluation by Semmes • Panoramic Group: 8 There was no significant
Weinstein monofilament (4.9%) difference between
neurosensoric test, 2 P • CBCT Group: 8 panoramic and CBCT
discrimination test, brush-­ (5.1%) groups (p = 1.0)
stroke test, pin-­prick test, and Subjective evaluation: Subjective evaluation:
thermal discrimination test • Panoramic Group: 9 There was no significant
Subjective evaluation: Report (5.5%) difference between
of neurosensoric changes in • CBCT Group: 11 panoramic and CBCT
the lip and chin by patients (7.1%) groups (p = 0.64)
Petersen, Vaeth 230 • Panoramic: n = 116 Evaluation by Semmes • Panoramic Group: 12 There was no significant
and Wenzel18 • CBCT: n = 114 Weinstein monofilament (10.5%) difference between
neurosensoric test. In • CBCT Group: 20 panoramic and CBCT
addition, the patients used a (17.5%) groups (p = 0.13)
visual analogue scale (VAS) to
report sensory disturbances
and to overrule any negative
Semmes Weinstein finding

The first post-­

operative evaluation of paresthesia the studies included also evaluated permanent pares-
of the included RCTs was verified 7 days after surgery thesia, considered the type that lasts beyond the period
and was denominated temporary paresthesia. Two of of 6 months.17,18 However, fewer than 1% of the cases

Figure 3  Risk of bias for the five domains included in the scale Revised Cochrane Risk of Bias Tool for Randomized Trials (RoB 2.0).

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Figure 4  Meta-­analysis of the four RTCs to verify whether CBCT images reduced the risk of temporary paresthesia in IAN in third molar
extractions. A fixed effect model and the relative risk were used to evaluate the outcome.
presented permanent paresthesia.2,3 Therefore, although
temporary paresthesia is a transitory condition, it is
the most frequent cause of discomfort and anxiety
in patients, and for this reason it was considered the
outcome of our study.2,3 It is important to use neuro-
sensory tests before the surgical intervention, because
some of the participant patients may have some change
in IAN sensitivity before undergoing surgery. When this
is not identified, it may cause bias in the result. Guerrero
et al.15,16 and Petersen, Vaeth and Wenzel18 performed
neurosensory evaluation of the lip and chin prior to
surgery.
The results pointed out, with moderate certainty, that
performing CBCT did not reduce the chances of tempo-
rary paresthesia occurring, thus allowing us to conclude
that there is no need to have the tomographic examina-
tion (CBCT) performed in addition to panoramic radi-
ography, for cases of mandibular third molars that were
closely related to the mandibular canal. These results
were corroborated by the data of the meta-­analysis that
showed no effect between the two interventions (CBCT
and panoramic radiograph) on reducing the risk of
temporary paresthesia of the IAN during third molar
extraction procedures. As the effective dose of radia-
tion is high in comparison of that of panoramic radi-
ography, and the benefits were not significant, CBCT
did not present sufficient evidence to be indicated as
the exam of first choice. Whenever possible, alterna-
tive techniques that involve less or no radiation must be
considered.24,25
The level of evidence was considered moderate due
problems of imprecision. The number of events for cate-
gorical data was low (<300), not achieving the minimum
required for the optimal information size (OIS). This
resulted in large 95% CI. We found no problems of
inconsistency, once all four studies included had similar
effect estimates, overlap of 95% CI, without statistical
heterogeneity and no problems due publication bias.26,27
It was believed that two studies’ sample15,16 could have
been the same in both studies. Authors were contacted,
and they confirmed that the samples of the two studies
were different. Therefore, both were included in the
evaluation of the results and meta-­analysis. Searches
in the Clinical Trials, ICTRP and Google Scholar were
conducted to avoid this possible publication bias.
We did not find serious problem of risk of bias.
The only problem was regarding allocation sequence
Dentomaxillofac
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Del Lhano et al
concealment in two studies.15,16 Although the allocation
sequence was randomized for all the studies, in two of
them15,16 this sequence was not concealed until the inter-
ventions were performed. With regard to blinding of
those involved in the study, in three articles,15–17 both
the patients and surgeons who performed the extraction
were not blinded, which is impossible to blind in this
kind of study. In these studies, only the evaluators of
the outcome, who performed the neurosensory test,
did not know the randomizationgroup (CBCT or
panoramic radiography) to which the patients belonged,
which is a strong point of the trials. On the other hand,
the study of Petersen, Vaeth and Wenzel18 blinded all
involved—patients, surgeons and outcome evaluators.
All the patients underwent panoramic radiography and
CBCT, but in those allocated to the “panoramic group,”
the CBCT exam was performed without exposure to
radiation (simulation). The surgeons who performed
the extractions belonged to another centre and did not
know about the project.
It is worth emphasizing that this systematic review
evaluated one single post-­ operative complication of
third molar extractions—temporary paresthesia—and
therefore no inferences can be made for other compli-
cations such as exposure of the IAN, trismus, haemor-
rhage, infection, alveolar osteitis or ecchymosis, which
are also related to these surgeries. Moreover, surgeons
who have only the panoramic radiograph to use for
surgical planning are believed to possibly be more
careful during their technical procedures, because they
know the limitations of two-­dimensionality and super-
imposition of these exams. Studies have suggested
that the additional information provided by CBCT
could change the surgical approach and thus prevent
injury to the IAN.28,29 However, this hypothesis was not
confirmed in the present review, because the fact that
the surgeon had knowledge about the localization of the
canal (either by CBCT or panoramic radiograph) was
not capable of reducing the occurrence of lesions.
The results obtained in this meta-­analysis endorsed
the current recommendation that CBCT imaging of
the mandibular third molar should not be applied as
a routine method before removal of mandibular third
molars, it should only be applied when the surgeon has
a very specific clinical question in an individual patient
case that cannot be answered by conventional imaging.30
If new RCTs are developed with the same objective, it is
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worth highlighting the need to improve the allocation

and blinding of the participants for reducing the risk

MODERATE

Total number of events is lower than optimal information size (OIS) considered the minimum ideal (300) and 95% CI cross-­the line of null effect. For these reasons, rated down one level due imprecision.
of bias.

Certainty

⨁⨁⨁◯
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