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CLINICIANS CORNER

Temporary lip paresthesia during orthodontic


molar distalization: Report of a case
Giampietro Farronato,a Umberto Garagiola,b Davide Farronato,c Luca Bolzoni,d and Elena Parazzolid
Milan, Italy
Lip paresthesia during mandibular molar orthodontic distalization is rare. When it occurs, it is often related
to excessive dimensions of the mandibular second molar roots. In this clinical report, we describe a patient
who developed lip paresthesia during orthodontic treatment. The paresthesia was relieved by immediate
interruption of the forces applied to the mandibular second molars and pharmacologic therapy. Before fixed
orthodontic treatment proceeds in patients with large tooth roots, it is important to diagnose the relationship
between the roots and the mandibular canal to prevent nerve numbness and damage. (Am J Orthod
Dentofacial Orthop 2008;133:898-901)

emporary paresthesia of the lower lip can result


from various pathologic conditions, including
benign causes and underlying systemic and
neoplastic diseases. It can be the only symptom of a
compound odontoma in the mental foramen region,1 or
it can be associated with metastatic tumors in the
mandible.2 It might be the result of orthognathic surgery to the mandible3-6 after endodontic treatment,7,8 or
after removal of the mandibular third molar.9,10 Temporary mental paresthesia of the lower lip with a fixed
appliance during conventional orthodontic treatment of
an adult is a rare complication.11,12 Some authors13-15
have described a few cases of numbness of the lower
lip. We report an additional case of such a sensory
disturbance.
CASE REPORT

A 16-year-old boy came to a private orthodontic


office for tooth alignment. His anamnesis was noncontributory, and he had no disease. He went through the
usual diagnostic examinations: impressions, intraoral
and facial photos, panoramic radiograph, lateral teleradiograph, and cephalometric tracing.
The clinical diagnosis was skeletal Class I malocFrom the University of Milan, Milan, Italy.
a
Professor and chairman, Department of Orthodontics and Gnathology, School
of Dentistry, Dental and Stomatologic Clinic, Istituti Clinici di Perfezionamento.
b
Assistant professor, Department of Oral Surgery and Orthodontics, School of
Dentistry.
c
Lecturer, Department of Oral Surgery and Orthodontics, School of Dentistry.
d
Lecturer, Department of Orthodontics, School of Dentistry.
Reprint requests to: Giampietro Farronato, University of Milan, Universit
degli Studi di Milano, Clinica Odontoiatrica, via Commenda, 10, Milan, Italy;
e-mail, giampietro.farronato@unimi.it.
Submitted, June 2006; revised and accepted, September 2006.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.09.051

898

clusion, dental deepbite with biprotrusion, and vertical


growth prediction. The treatment plan suggested 4
premolar extractions, but the patient refused this. Consequently, an alternative treatment was proposed that
included the extraction of the mandibular third molars
and the placement of a rapid palatal expander and fixed
orthodontic appliances to distalize the first and second
molars of both arches.
During treatment with the fixed appliances, opencoil springs, applied between the first and second
mandibular molars to distalize them, were activated
periodically.
After 6 months of the coil springs being applied,
paresthesia developed suddenly, specifically in the area of
innervation of the mandibular right nerve. The patient was
sent to the Department of Orthodontics of the University
of Milan, Italy, for a consultation. After evaluation, a
computerized tomography (CT) scan and a panoramic
radiograph were requested. The radiologic examinations
showed excessive growth and length of the roots of the
mandibular second molars, which, with the distalization,
led to interference with the mandibular canal and compression of the mandibular nerve (Fig 1). To heal the
nerve lesion, the first actions were to remove the coil
springs and the bands on the mandibular second molars
and grind them to prevent strong contact with their
antagonists. In addition, pharmacologic therapy was prescribed, consisting of an anti-inflammatory drug such as
serratiopeptidase (Danzen, Takeda, Rome, Italy; 10 mg,
orally, 3 times a day for 1 week) and vitamin B (Be-total,
Pfizer, Milan, Italy; 100 mg, daily for 10 days). Immediately after removing the coil springs and the bands and
grinding the occlusal surfaces of the mandibular second
molars, the symptoms started to diminish. They disappeared within 2 weeks, leading to complete recovery. A
CT scan 2 months later showed a similar relationship

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 133, Number 6

Farronato et al 899

Fig 1. Records at symptom onset: A, panoramic radiograph; B and D, CT scans, right side; C and
E, CT scans, left side.

between the root apices and the mandibular canal (Fig 2).
The original orthodontic alignment treatment was completed, simply avoiding the bands on the second molars
and maintaining all other appliances in place. At the end
of alignment, a retainer was prescribed. The patient
suffered no further paresthesia and recovered completely.
DISCUSSION

According to the literature, a close relationship


between the mandibular canal and the roots of the first

and second molars, particularly the distal roots, is


unusual.11,12 Some authors13-15 described a rare clinical
case of a buccal position of the mandibular left second
molar roots in an intimate relationship with the mandibular canal. During the alignment and leveling of an
extremely lingually inclined tooth, the root apices were
moved against the mandibular nerve, causing paresthesia. Usually, the mandibular canal is far buccal to the
molar roots and slightly buccal to the premolar toots.16
Closer proximity is seen in ectopic or impacted teeth,

900 Farronato et al

American Journal of Orthodontics and Dentofacial Orthopedics


June 2008

Fig 2. Two months after recovery: A, panoramic radiograph; B and D, CT scans, right side; C and
E, CT scans, left side.

with long or abnormally large roots, and when the


mandibular body is not high. When intimate contact
occurs between the molar roots and the mandibular
canal, the cortical bone that covers the canal can be thin
or deficient; this leads to immediate paresthesia if the
orthodontic tooth movement invades the mandibular
canal.

Lower lip paresthesia as a result of orthodontic


treatment is an extremely rare event12,13,15 related to
abnormally long roots and close contact with the
mandibular canal.16 No specific tests or measurements
can predict this risk, and we can state only that the
original panoramic radiograph showed unusually and
excessively long mandibular second molar roots close

Farronato et al 901

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 133, Number 6

to the mandibular canal. When mandibular molar distalization is contemplated in treatment, detailed analysis of the panoramic radiograph might be useful to
prevent this unusual occurrence. In our case, the panoramic radiograph showed excessively long molar roots
near the mandibular canal bilaterally, although the
symptoms developed only on the right side.

8.
9.

10.

REFERENCES
1. Borner L, Oberman M, Shteyer A. Mental nerve neuropathy
associated with compound odontoma. Oral Surg Oral Med Oral
Pathol 1987;63:658-60.
2. Jerjes W, Swinson B, Banu B, Al Khawalde M, Hopper C.
Paresthesia of the lip and chin area resolved by endodontic
treatment: a case report and review of literature. Br Dent J
2005;198:743-5.
3. Jonsson E, Svartz K, Welander U. Sagittal split osteotomy: I.
Immediate postoperative conditions. Int J Oral Surg 1979;8:75-81.
4. Martis CS. Complications after mandibular sagittal split osteotomy. J Oral Maxillofac Surg 1984;42:101-7.
5. Leira JI, Gilhuus-Moe OT. Sensory impairment following sagittal split osteotomy for correction of mandibular retrognathism.
Int J Adult Orthod Orthognath Surg 1991;6:161-7.
6. Proffit WR, White RP. Surgical orthodontic treatment. St Louis:
Mosby-Year Book; 1991.
7. Ahlgren FK, Johannessen AC, Hellem S. Displaced calcium
hydroxide paste causing inferior alveolar nerve paresthesia:

11.
12.

13.

14.

15.

16.

report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2003;96:734-7.
Allard KU. Paresthesiaas consequence of a controversial
root-filling material? A case report. Int Endod J 1986;19:205-8.
Wofford DT, Miller RI. Prospective study of dysesthesia following odontectomy of impacted mandibular third molars. J Oral
Maxillofac Surg 1987;45:15-9.
Kipp DP, Goldstein BH, Weiss WW Jr. Dysesthesia after
mandibular third molar surgery: a retrospective study and analysis of 1,377 surgical procedures. J Am Dent Assoc 1980;100:
185-92.
Stirrups DR. Temporary mental paresthesia: an unusual complication of orthodontic treatment. Br J Orthod 1985;12:87-9.
Tang NC, Selwyn-Barnett BJ, Blight SJ. Lip paresthesia associated with orthodontic treatmenta case report. Br Dent J
1994;176:29-30.
Krogstad O, Omland G. Temporary paresthesia of the lower lip:
a complication of orthodontic treatment. A case report. Br J
Orthod 1997;24:13-5.
Caruso EM, Leggitt JM, Newtom L. QR-DVT 9000 imaging
used to confirm a clinical diagnosis of iatrogenic mandibular
nerve paresthesia. J Calif Dent Assoc 2003;31:843-5.
Willy PJ, Brennan P, Moore J. Temporary mental nerve paresthesia secondary to orthodontic treatment. A case report and
review. Br Dent J 2004;196:83-4.
Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship
between the apices of the lower molars and mandibular
canala radiographic study. Oral Surg Oral Med Oral Pathol
1986;62:595-602.