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Research paper:
Dentoalveolar surgery
Abstract. The position of the lingual nerve in the mandibular third molar region
was measured and documented in 68 cadaver dissections (34 adult cadaver heads).
In 8.8% of the dissections, the lingual nerve was found at or above the level of the
alveolar crest. In the horizontal plane, the nerve contacted the lingual plate of the
third molar in 57.4% of the specimens. There was also a significant relationship
between the degree of mandibular crest atrophy and the distance from the nerve to
the molar region. The distance decreased with the degree of atrophy. There was no
Key words: third molar surgery; nerve injury;
significant difference between the two sides of the head. These results demonstrate lingual paresthesia; protection of the lingual
the vulnerability of the lingual nerve as it medially passes the mandibular third nerve; human anatomy.
molar and may help avoid lingual damage during surgery in the third molar and
retromolar region of the mandible. Accepted for publication 1 April 2001
The anatomic proximity of the lingual esthesia after surgical insertion of hypogeusia of one half of the tongue is
nerve to the mandibular third molar implants3. calculated to be 1:2 million after local
region plays an important role in plan- The risk of damaging the lingual nerve anaesthesia9. The incidence of a persist-
ning and performing surgical interven- during mandibular wisdom tooth sur- ent sensory deficit after osteotomy is
tions in this area. Nerve injury is gery differs in the literature. Horch reported to be 0.5–2% in English litera-
possible during removal of the third reports an injury incidence of 0.05%10 ture4,13,19. A-A gives an
molars, osteotomy of the mandibular and H 0.04%. About 250 000 11.5% incidence of reversible dysesthesia
branch, alveolar crest graft and by injec- wisdom teeth per year were removed in after mandibular wisdom tooth surgery2.
tion of local anaesthesia. Even excision the 1980’s in the old federal states of Thus, extensive knowledge about the
during tumour removal or the sequelae Germany. An incidence of 0.05% means position of nerves in the mandibular
of trauma may injure the nerve1,20,23. 125 nerve lesions per year. The prob- third molar region is indispensable for
There are also reports of lingual par- ability of irreversible numbness and surgery in this area.
0901-5027/01/040333+06 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons
334 Hölzle et al.
Discussion
Fig. 4. Double foramen mentale with two mental fascicles exiting from each. m: N. mentalis, F: After the lingual nerve passes through
Foramen mentale, c: top view of mandibular crest. the deep lateral facial region, it enters
the floor of the mouth between the man-
dibular branch and the medial pterygoid
muscle. Behind the dorsal edge of the
mylohyoid muscle, the sublingual space
is broadly connected to the submandibu-
lar space24. Like the styloglossus muscle,
the nerve is also at the aboral end of
the sublingual oral sinus at the level
of the lower third molar just beneath the
mucosa and is only separated by this and
some connective tissue7. Nerve injuries
in this region can predominately be
attributed to dental interventions and
the close spatial relationship of the nerve
to the wisdom tooth region24.
Numerous authors describe the nerve
but discuss the variability of its position
to a much lesser degree. Our measure-
ments quantify the position of the nerve
and provide information about its
incidence and range.
In the present study, the mean
Fig. 5. Nerve anastomosis between the mylohyoid and lingual nerves. l: N. lingualis, y: N. distance of the lingual nerve to the
mylohyoideus, a: nerve anastomosis, t: tongue, c: mandibular crest. lingual mandibular crest surface is
0.86 mm1 mm at the level of point A.
Scheffe test showed that the more dentu- Two corpses had a unilateral nerve The nerve directly contacted the bone in
lous the jaw, the less marked the man- anastomosis (as demonstrated in Fig. 5) 57.4% and the greatest distance was
dibular crest atrophy (right: P=0.02; left between the sensory lingual nerve and 4 mm. K & C,
P=0.06). the motor mylohyoid nerve from the who also examined 34 heads, reported a
inferior alveolar nerve. This corresponds distance of 0.59 mm0.9 mm. There
Pre-existing variations
to an incidence of just under 3%. was bone contact in 62% of the cases12.
In these cases, there was a pronounced In 20 head specimens, P et al.
One corpse had a double foramen men- anastomosis with a diameter of over found a horizontal distance of
tale on one side. There were two mental 1 mm. In one case, the anastomotic 3.45 mm1.48 mm. The values ranged
nerve fascicles exiting from each of the branch to the lingual nerve was larger from 1.0 mm to 7.0 mm17. Using MRI,
foramina. than the distal mylohyoid component. M et al. examined the position of
A bilateral double foramen mentale The submandibular duct (of Wharton) the lingual nerve in 10 volunteers aged
was seen in one head specimen. On the primarily crosses over the lingual nerve 21–35 years. All subjects had rudimen-
right side, two nerves each originated in the premolar region. In one corpse, tary lower wisdom teeth and no maxillo-
from the foramina and, on the left, two the unilateral duct was tied off by facial surgery in their history. The
from the cranial and one from the a network of lingual branches. In a horizontal distance here to the lingual
caudally located foramen (Fig. 4). total of four corpses, Wharton’s duct aspect of the mandible in the wisdom
Anatomic position of the lingual nerve in the mandibular third molar region 337
tooth region was 2.53 mm0.67 mm. In nerve damage8. Our incision directly up Peripheral polyfascicular reconstruction
five of the 20 cases (25%), the nerve to the ascending branch is certainly the of the lingual nerve can be done in
directly contacted the bone. The mean most medial that should be selected. In individual cases and its fasciculus con-
vertical distance of the nerve to upper the surgical removal of wisdom teeth, it nected to that of the sural nerve with a
mandibular crest edge was 2.75 mm facilitates distolingual exposure of the perineural suture8.
0.97 mm with range of 1.52–4.61 mm14. mucoperiosteum flap and subsequent The correlation between the position
In our study, the vertical distance was mobilization of the tooth, but carries the of the lingual nerve to the upper man-
7.83 mm with a standard deviation of risk of a lingual lesion. In view of the dibular crest edge and mandibular crest
1.65 mm and a range of 4.5–14 mm. results, a more buccal relieving incision atrophy has hitherto not been the subject
P et al. found a vertical distance is safer and is therefore recommended. of extensive studies. Although this con-
of 8.32 mm (standard deviation: There is a clear discrepancy in the mean nection seems obvious, it is not necessar-
4.05 mm)17. K & C- nerve diameters given in the literature. ily the case. This study shows that the
measured only 2.28 mm1.96 mm, M et al. reported the lingual nerve extent of atrophy is related to age but
although the values extended from 2 mm diameter to be 2.54 mm with a range of even more to edentulousness. However,
over to 7 mm below the crest12. All four 1.58–3.13 mm. The shape of the nerve since there is often a loss of muscle tone
studies mentioned deal with the distance was round in 45% of the cases, oval in and connective tissue tension with
of the nerve from the mandibular crest in 30% and flat in 25%14. K & advanced age, the nerve may also
its further mesial course in the paralin- C found a mean nerve diam- descend into the floor of the mouth and
gual space. In our study, the mean dis- eter of 1.86 mm. The nerves were round thus not change its relative position to
tance was 5.91 mm with a standard in 61.7% of the cases, oval in 17.6% and the mandibular crest. Further studies are
deviation of 2.3 mm. There was a con- flat in 20.5%. Three of the flat nerves necessary to confirm this connection.
siderable range of values with a maximal were only 0.5 mm thick. The shape did
The ratio of the foramen-upper man-
distance of 12 mm, and, in a total of six not correlate to the distance from the
dibular crest edge to the entire mandibu-
head dissections, the nerve was found at jaw bone12.
lar crest height at this position is a very
or above the alveolar crest. The authors P et al. reported a mean nerve
suitable measure of mandibular crest
largely agree on this finding. The per- diameter of 3.45 mm. The standard
atrophy and agrees with the ‘prima
centage of nerves found at or above the deviation was 1.00 mm with a range of
vista’ estimation of atrophy into ‘high’,
mandibular crest and thus particularly 2.5–4.5 mm17. The mean nerve diameter
endangered by this exposed position is in P et al. is 80% above that ‘moderate’ and ‘slight’.
8.82% in our study, 10% in M et al. reported by K & C- At this point it should be considered,
using MRI, 15% in P et al. and . Moreover, lowest value found by whether this method would also be
17.6% in K & C- P et al. did not even reach the suited for radiological classification
12,14,17. The latter even reported one mean value of K & C- based on pantomograms. One only has
nerve that passed through the retro- . In our study the mean diameter to measure two lengths on the X-ray and
molar region 2 mm above the lingual was 2.74 mm with a standard deviation divide them. Manufacturers of X-ray
crest border at the level of the occlusal of 0.3 mm. Values ranged from 1.9– devices use different magnification fac-
surface of an impacted wisdom tooth 3.6 mm. The nerves were oval in 50.0% tors. However, since both values are
and would, thus, have certainly been of the cases, round in 32.3% and flat in placed in relationship to each other with
dissected by a classical incision12. 17.7%. The shape of the nerve did not the same magnification, the ratio
The mean distance of point B from correlate to the distance from the remains constant and can thus be com-
point A in the sagittal plane was alveolar bone. Changes of shape of pared to the diverse magnifications of
5.97 mm with a standard deviation of nerves may be due to post-mortem arte- other pantomograms. In addition, the
1.29 mm. P et al. found a mean facts and/or formalin fixation. To this foramen mentale is almost always clearly
distance of 4.45 mm with a standard issue we neither found publications nor visible and usually located between the
deviation of 1.48 mm17. At the shortest experienced anatomists or pathologists. mandible premolars in dentulous jaws,
distance from the nerve to point A, point To answer this question we looked at the so that the teeth do not interfere with the
B was distal to point A in both studies. shape of the lingual nerve in 15 fresh determination of the entire mandibular
The mean sagittal course of the nerve cadavers without fixative added. In this crest height. This would provide a simple
from point B to its medial bend to- 30 nerves measured it was oval in 46.7%, method for classifying mandibular atro-
wards the tongue (segment BD) was round in 33.3% and flat in 20.0%. We phy and promote understanding among
27.7 mm5.69 mm in P et al. and therefore conclude the influence of post- dentists.
27.47 mm3.3 mm in our study17. mortem formalin fixation on the shape A total of three double mental
The shortest distance of the lingual of the nerve as minimal. foramina, each with a nerve exit, were
nerve to the distal relieving incision was The nerve started to ramify a mean of determined in 68 prepared mandibular
a mean 4.41 mm. In one head dissection, 20.62 mm mesially from point C. This dissections. In two mandibular dissec-
the nerve was bisected by the distal site was 57.13% of the distance between tions, atrophy was so severe that the
relieving incision. K & C and the foramen mentale. In dentu- mental nerve exited at the mandibular
C reported a situation with lous jaws, ramification was primarily crest.
similar superficial nerve course12. located in the distal premolar region and It is exactly during abscess incision
H, who studied lingual is thus somewhat mesial to the position that the mental nerve is easily dissected,
nerve damage in Schleswig-Holstein, the reported by N & H15. since there is no visualization as in other
northern part of Germany, from 1981 to This site is clinically relevant if, for operations like apicectomy11. A pre-
1986, determined that an incision too far example, a sural nerve graft is required operative X-ray should therefore always
in the lingual direction promotes lingual for reconstruction of a nerve lesion. be performed.
338 Hölzle et al.
In two corpses, there was a pro- in the mesial paralingual region, if there mandibular third molar region. J Oral
nounced nerve anastomosis on one side is marked mandibular crest atrophy. Maxillofac Surg 1984: 42: 565–567.
between the sensory lingual nerve and This is not only true for oral surgical 13. M D. Lingual nerve damage follow-
the motor mylohyoid nerve from the procedures like osteotomies and ing lower third molar surgery. Int J Oral
inferior alveolar nerve, in one case with a excisions but also for the insertion of Maxillofac Surg 1988: 17: 290–294.
14. M M, H LE, S HW,
diameter of more than 1 mm. L & intraosseous implants.
C DW. Assessment of the lingual
W also report a fiber change nerve in the third molar region using
between these two nerves16,24. magnetic resonance imaging. J Oral
Acknowledgments. The authors would
B described very fine anatomical Maxillofac Surg 1997: 55: 134–137.
like to express their many thanks to
branches between the lingual and mylo- 15. N FW, H JE. Anato-
Professor Graf, M.D., from the Institute
hyoid nerves5. S even refers mische Untersuchungen zur faszikulären
of Anatomy of the Free University,
to ‘Bichat’s nerve’22. F also found Struktur einzelner Hirnnerven als Grund-
Berlin for providing the study specimens
a connecting branch between these two lage zur Vermeidung von Mißerfolgen
as well as her kind support during the
nerves6. R & M18, who studied bei der Mikrochirurgischen Nervnaht.
entire study. Fortschr Kiefer Gesichtschir 1985: 30:
the course of the lingual nerve in 48 head
dissections, reported this connection in 51–54.
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present study was less than a tenth of Maxillofac Surg 1997: 35: 170–172. Menschen. Anat Anz 1981: 149: 64–71.
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the value reported by R & M18. 19. R JP. Permanent damage to inferior
W H, N I. Lingual paresthe- alveolar and lingual nerves during the
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the wisdom tooth region was demon- removal of impacted mandibular third
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6. F E. Zwei Sonderfälle des N. lingua- 22. S J. A propos du nerf de
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nerve may lie over the bone in the soft 1932: 994. G. Clinical consequences of complaints
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tal relieving incision for wisdom tooth lingualis—Eine klinische und tierexperi- mandibular third molar. Int J Oral Surg
osteotomy, should not be made medial mentelle Studie. Habilitationsschriften 1977: 6: 29.
to the ascending branch because the der Zahn-, Mund- und Kieferheilkunde, 24. V L T, W W. Praktische
Quintessenz Verlags-GmbH, Berlin 1989:
variability of the nerve and its possible Anatomie Bd.1, Teil 2: Hals. Berlin
21–22. Göttingen Heidelberg: Springer Verlag
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lingualis—Eine klinische und tierexperi-
molar is also suited as a guideline for mentelle Studie. Habilitationsschriften
orientation. The incision should be made der Zahn-, Mund- und Kieferheilkunde, Address:
at a 45 angle to this tangent in the Quintessenz Verlags-GmbH, Berlin 1989: Dr. med. Dr. med. dent.
buccal direction. Moreover, during free 81–82. Frank Hölzle
fraising of the lower wisdom tooth, 10. H HH. Iatrogene Nervläsionen bei Klinik für Mund-, Kiefer- und Plastische
attention should be paid to the fact that der zahnärztlichen Behandlung. Gesichtschirurgie
a raspatory should be pushed disto- Zahnärztl Mitt 1984: 7: 708–715. Knappschaftskrankenhaus
11. H HH. Zahnärztliche Chirurgie. Klinikum der Ruhr-Universität Bochum
lingually between the periosteum and
Praxis der Zahnheilkunde 9. 3. Auflage, In der Schornau 23–25
bone in order to protect the periosteum Urban & Schwarzenberg, München Wien 44892 Bochum
and lingual nerve9. Baltimore 1995: 51–52. Germany
Furthermore, a relatively high 12. K JE, C JG. Clini- Tel.: +49 (0) 234-299 3500
position of the nerves must be taken into cal and anatomic observations on the Fax: +49 (0) 234-299 3509
account for surgical interventions even relationship of the lingual nerve to the E-mail: frank.hoelzle@ruhr-uni-bochum.de