CLINICAL CASE

Dent. Med. Probl. 2006, 43, 2, 309312 ISSN 1644387X

Copyright by Silesian Piasts University of Medicine in Wrocaw and Polish Stomatological Association

JAN NIENARTOWICZ, HANNA GERBERLESZCZYSZYN

Iatrogenic Sensation Disorders Caused by Lower Alveolar Nerve Injury Due to Complications After Wisdom Tooth Extraction
Jatrogenne zaburzenia czucia spowodowane uszkodzeniem nerwu zbodoowego dolnego wskutek powikanego usuwania zba mdroci
Department of Oral Maxillofacial Surgery, Silesian Piasts University of Medicine in Wrocaw

Abstract
In young people, the most often surgical procedure in the oral cavity is retented wisdom tooth extraction. In some cases,on the basis of clinical and radiological examinations, there is a possibility of complications in the form of lower alveolar or tongue nerves dysfunction. A patient should be informed about this kind of threat. The authors present the case of permanent lower alveolar nerve injury during the surgical procedure of a retented wisdom tooth extraction. Finally,the procedure was successfully completed only 13 months after the first failed attempt. However,the ailment was neither decreased or relieved both after the surgery and in the follow up two years after. The procedure was qualified as prophylactic activity preventing from further inflammation formation (Dent. Med. Probl. 2006, 43, 2, 309312). Key words: retented teeth extraction, complications.

Streszczenie
Do najczciej wykonywanych zabiegw chirurgicznych w obrbie jamy ustnej, zwaszcza u modych osb, nale y operacyjne usuwanie zatrzymanych zbw mdroci. Na podstawie badania klinicznego i radiologicznego w niektrych przypadkach naley si liczy z moliwoci powika w postaci zaburzenia funkcji nerwu zbodo owego dolnego lub nerwu jzykowego. O moliwoci wystpienia tego rodzaju powika pacjenta naley koniecz nie poinformowa jeszcze przed zabiegiem. Autorzy przedstawiaj przypadek trwaego uszkodzenia nerwu zbo doowego dolnego podczas prby chirurgicznego usuwania zba zatrzymanego. Ostatecznie dokoczono ekstrak cj chirurgiczn zatrzymanego dolnego zba mdroci dopiero po trzynastu miesicach od pierwszego nieudanego zabiegu. Nie uzyskano jednak zmniejszenia ani ustpienia dolegliwoci, zarwno po zabiegu, jak i w badaniu kon trolnym dwa lata po zabiegu. Przyjto jednak, e zabieg mia zadanie profilaktyczne zabezpieczajce przed powsta niem stanu zapalnego (Dent. Med. Probl. 2006, 43, 2, 309312). Sowa kluczowe: usuwanie zbw zatrzymanych, powikania.

Inferior alveolar nerve is the biggest branch of the mandibular nerve. Through its ramifications such as mylohyoid nerve, it furnishes the anterior belly of the biventer muscle, innervates mentum skin as well as the skin and mucous membrane of the lower lip. In turn,inferior gingival branches partially supply gingivae buccal surface, inter den tal papilla and periodontium and inferior alveolar branches forming inferior dental plexus reach den tal pulp through apical foramina of lower teeth [1].

Inferior alveolar nerve injury can result from: trigeminal nerve neuralgia treatment with the use of blocks, anaesthesia complications, traumatic mandibular fractures or surgical treatment with nerve damaging chips repositioning. It can also be the effect of mandible orthognathic procedures during mesiocclusion treatment (the patient is always informed of the possible complication before the surgery), pathological processes such as neoplastic tumours, cysts, osseous inflammations

310
or surgical procedures in mandible which are usu ally connected with teeth extractions or prolifera tions removal when mental or alveolar nerves get damaged. Pre prosthetic activities, implantation or reconstructive procedures as well as neoplasms treatment can be the reasons for nerve damage. There are three kinds of nerve damage: nerve temporary paralysis without degenera tion (neurapraxia), axone continuity break without connective tissue neurolemma continuity break (axonotmesis), nerve continuity break (neurotmesis) [2]. Diagnosis of nerve damage kind is carried on in retrospective way but the knowledge concern ing each type is indispensable for the treatment progress evaluation. Neurapraxia is the most lenient form as the damage does not cause axone or neurolemma rupture. Blunt damage causes nerve distension, inflammation or nerve local ischaemia. After several days or weeks the func tion is restored. Axonotmesis takes place when axones continuity is broken and the perineurium sheath is preserved e.g. On the severe blunt trau ma, nerve distension or crushing, perineurium sheath preservation usually enables axones regen eration with 26 month nerve dysfunction. Neurotmesis is nerve continuity complete rup ture due to trauma, gunshot wounds or iatrogenic surgical procedure.The prognosis of the nerve autophatic regeneration is doubtful in such cases, however it is possible when the damaged nerve endings are favourably closely placed. The healing process consists of two stages: degenerative and regenerative. Degeneration is a segmental demyelination with myelin sheath dis integration. This process is accompanied by slow ness or inability of nerve impulses transmission. The symptoms include: paraesthesia, disesthesia, hyperesthesia or hypoesthesia. Nerve degeneration may appear in the second type as Wallerians degeneration when axones as well as myelin sheath in a distal segment from the rupture site undergo complete break up. Then, the nerve transmission is totally discontinued. Peripherial nerve regeneration starts after the damage and consists on fibres growth to proximal stump along the preserved canal of Schwanns cells. The growth equal to 11,5mm in 24 hours appears up to the site of nerve supply or it is blocked by connective tissue or bone. At the end of nerve regeneration period, in the hypoesthesia area, the patient may experience paraesthesia or disthesia. When the nerve cone growth is blocked by cicatrical connective tissue, the nerve finds col lateral course or forms traumatic neurinoma in the chaotic system of nerve fibres which gives reason for pain syndromes.

J. NIENARTOWICZ, H. GERBERLESZCZYSZYN

Nerve external compression resulting from the pressure caused by bone, tooth root, implant, bro ken tool or connective tissue scar is visualised with radiologic methods and confirms the need of operative treatment. Inferior alveolar nerve perma nent damage occurs in 3,6% of cases after lower wisdom tooth extraction and temporary paralysis in 8% of cases [3]. Sedagbatfar et al. report the percentage of this kind complications ranging from 0.65.3% and the nerve total damage may refer to less than 1% of patients. They point at the retented teeth relation to the nerve which, in radi ological assessment, enables complications prog nosis in 2438% [4]. Renton et al. describe the injuries from 0.013.6% [5], others 0.48.4% [6] or 3.9%. However, in the group of patients below 20 with the tooth horizontal position [7], in 0.91% of patients, paraesthesia decreased in 6 months after the surgery [8]. In their monograph [9], Tetsch i Wagner report about temporary hypoes thesia in the region of inferior alveolar nerve in the group of 1214 year old patients 1,5% of cases, in older patients in 12% patients and only in 1 case it lasted 12 months after the surgery. This compli cation frequency is not only influenced by the retented tooth position but also the choice of the surgical method and the doctor experience. In some cases, however, on the basis of clinical and radiological examinations, the patient should be informed about possible complication of this kind. This should be done especially when in Xray image, mandibular tooth superposition on the canal or canal course change are observed [9]. In every case, indications to surgical removal of the mandibular retented wisdom tooth should be con sidered carefully. Among many common indications, prophylac tic indications constitute 62.2% of cases and the therapeutic ones 37.8% [9]. The authors want to present a rare case of complicated surgical removal of wisdom tooth accompanied by external compression of inferior alveolar nerve due to mandibular canal injury caused by displaced and impacted tooth root.

Case
A female patient aged 38 appeared in the Maxillofacial Surgery Dept. 13 months after failed procedure of retented left mandibular tooth extrac tion. Her main complaint had been numbness in the area of lower lip, alveolar process and teeth. Clinical examination, behind tooth 37, revealed distal deep gingival socket. Radiological examina tion, in lateraloblique mandible projection as well as pantomographic Xray examination showed

Iatrogenic Sensation Disorders Caused by Lower Nerve Injury

311

tooth 38 remains placed closely to mandibular canal (Fig. 1 and Fig. 2). The tooth position was typical for medialangle oblique retention. The sur gical procedure was carried on in general anaesthe sia. After mucous and periosteal flap formation (cut across alveolar process dorsum behind tooth 37 directed vertically to oral cavity chamber), cica trical tissue was removed and tooth 38 fragments were revealed with the bur removing the bone. The tooth crown was detached from the root removing tooth remains in two parts. Fig. 3 pre sents after resection tooth. Mandibular canal fornix damage was found and during the procedure, haemorrhage from vesselnerve boundle appeared.

Fig. 3. Retented tooth remains after the surgical extraction Ryc. 3. Pozostao zba zatrzymanego po jego opera cyjnym usuniciu

Four days after the surgery, the patient was dis charged home. The last follow up which took place two years after the procedure showed that the patient still suffered from the same complaints con nected with inferior alveolar nerve damage. However, the procedure of the wisdom tooth remains removal can be considered as preventive one from the inflammatory process formation.

Fig. 1. Lateraloblique Xray visualizing the remains of retented tooth after surgical trial Ryc. 1. Zdjcie RTG boczne skone przedstawiajce pozostao zba zatrzymanego po prbie ekstrakcji

Discussion
In the presented case, even the first procedure raised the danger of inferior alveolar nerve dys function. Before the surgical removal of retented wisdom tooth, Xray images are routinely assessed, prophylactic and therapeutic indications are considered and possible complications risk is discussed with the patient. The treatment unfavourable result could have also been influ enced by the remote time of surgical extraction completion as the patient was seen 13 months after the first and failed procedure. For sure, the doc tors skills and experience are indispensable in the successful treatment and complications minimiz ing. Although the complaints were neither elimi nated or alleviated, the treatment consisting on mandibular wisdom tooth remainings removal pre vented from further inflammation.

Fig. 2. Pantomographic Xray after not completed extraction Ryc. 2. Zdjcie RTG pantomograficzne wykonane po niedokoczonej ekstrakcji

References
[1] GADYSZ T., STYPUKOWSKA J., WALOCHA J., GRYGLEWSKI A., SKRZAT J.: Anatomiczne aspekty drg czucia blu z narzdw i tkanek jamy ustnej oraz najczciej stosowane metody znieczulenia miejscowego w tym obszarze anatomicznym. Poradnik Stomat. 2003, 5, 3, 512. [2] PETERSON L. J., ELLIS III E., HUPP J. R., TUCKER M. R.: Bl twarzowy, chirurgia stomatologiczna i szczkowotwa rzowa. Red. PogorzelskaStronczak B., Wydawnictwo Czelej, Lublin 2001, 744747. [3] RENTON T., HANKINS M., SPROATE C., MC GURK M.: A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Br. J. Oral Maxillofac. Surg. 2005, 43, 712.

312

J. NIENARTOWICZ, H. GERBERLESZCZYSZYN

[4] SEDAGBATFAR M., AUGUST M.A., DODSON T.B.: Panoramic radiographic findings as predictors of inferior alveolar nerve exposure following third molar extraction. J. Oral Maxillofac. Surg. 2005, 63, 37. [5] RENTON T., THEXTON A., HANKINS M., MC GURK M.: Quantitative thermosensory testing of the lingual and inferi or alveolar nerves in health and after iatrogenic injury. Br. J. Oral. Maxillofac. Surg. 2003, 41, 3642. [6] GUAN BAN A., GO SER WEE: Effect of exposed inferior alveolar neurovascular bundle during surgical removal of impacted lower third molars. J. Oral Maxillofac. Surg. 2004, 62, 592600. [7] BATAINEB A.B.: Sensory nerve impairment following mandibular third molar surgery. J. Oral Maxillofac. Surg. 2001, 59, 10121017. [8] GLLICHER D., GERLACH K. L.: Sensory impairment of the lingual and inferior alveolar nerves following removal of impacted mandibular third molars. Int. J. Oral Maxillofac. Surg. 2001, 30, 306312. [9] TETSCH P., WAGNER W.: Operacyjne usuwanie zba mdroci. Przek. Rytlowa W. Wydawnictwo Medyczne Sanmedia, Warszawa 1994, 25, 35, 107.

Address for correspondence:

Jan Nienartowicz Katedra i Klinika Chirurgii SzczkowoTwarzowej AM Chaubiski 5 50368 Wrocaw Tel.: +48 071 784 22 76 Email: nienartowicz@gmail.com Received: 13.03.2006 Revised: 28.03.2006 Accepted: 5.05.2006 Praca wpyna do Redakcji: 13.03.2006 r. Po recenzji: 28.03.2006 r. Zaakceptowano do druku: 5.05.2006 r.