“Abscess” as a perioperative risk factor for paresthesia after

third molar extraction under general anesthesia

Fulvia Costantinides, DDS,a Matteo Biasotto, DDS, PhD,b Dario Gregori, MA, PhD,c
Michele Maglione, MD, DDS,d and Roberto Di Lenarda, DDS,e Trieste and Torino, Italy
UNIVERSITY OF TRIESTE AND PADOVA

Objective. To evaluate postextractive neurological complications after third molar extraction under general anesthesia
and to identify correlations between the surgical procedure, the third molar-related pathology, and neurological
involvement.
Study design. The clinical records of 183 patients were analyzed for a total of 408 third molars extracted at the Dental
Clinic of Trieste (Italy). Individual effects of clinical data on the presence of paresthesia were evaluated by a logistic
regression model.
Results. Neurological involvement was observed in 13 patients (6.1%). No permanent inferior alveolar nerve damage
was found (0%) and only 1 patient presented a permanent lesion of the ipsilateral lingual nerve (0.3%). Pell and
Gregory classification and surgical difficulty were not associated with the incidence or gravity of neurological lesions
(P ⫽ NS). Among the pathologies associated with third molars, only the variable “abscess” presented a significant
correlation with paresthesia (OR 6.86; 95% CI 1.21-38.8; P ⫽ .029).
Conclusion. The percentage of nerve injuries agrees with the literature data, inclusion class, and surgical technique
seem not to influence paresthesia risk. Further studies are necessary to evaluate the role of infectious pathologies as a
cofactor in the development of neurological lesions after oral surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2009;107:e8-e13)

Removal of third molars represents one of the most
common surgical procedures in oral and maxillofacial
surgery.1 Malformation and malposition of these teeth,
often associated with altered eruption (partial or total
impaction) and invalidating conditions (pericoronitis,
abscesses, phlegmons), are indications for third molar
extraction.2-5 Surgical procedures are accompanied by
possible complications that may be divided into intra-
operative and postoperative. The first are a result of soft
tissue lesions (lacerations, emphysemas, dislocations),
vascular and neurological lesions (compression, trac-
tion, overheating, partial or total section by burs), bone
fractures (alveolar, mandibular, maxillary tuberosity),
or lesions to adjacent teeth and anatomic structures
a
Research associate, Dental Clinic, Clinical-University Department
of Biomedicine, University of Trieste, Italy.
b
Researcher, Dental Clinic, Clinical-University Department of Bio-
medicine, University of Trieste, Italy.
c involvement in a range from 0% to 2%.14
Associate Professor, Department of Environmental Medicine and
Public Health, University of Padova, Italy.
d
Associate Professor, Dental Clinic, Clinical-University Department
of Biomedicine, University of Trieste, Italy.
e
Full Professor, The Dean of the Dental Clinic, Clinical-University
Department of Biomedicine, University of Trieste, Italy.
Received for publication Aug 21, 2008; returned for revision Sep 29,
2008; accepted for publication Oct 16, 2008.
1079-2104/$ - see front matter
© 2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2008.10.014
(luxation, avulsion, periodontal involvement, fracture,
oroantral communication). Postoperative complications
are caused by soft tissue lesions (swelling, pain, tris-
mus, dysphagia), vascular involvement (hemorrhage,
ecchymoses, hematomas), and infection (alveolitis, os-
teitis).6,7
Neurological involvement represents an infrequent
but serious complication associated with the removal of
mandibular third molars. As previously reported, infe-
rior alveolar injury ranges from 0.6% to 5.8%.8 Histor-
ical studies have shown the incidence of lingual nerve
injuries to be variable and depend on a number of
factors including techniques used, with rates between
0.2% and 1.6%.9-12
Few data are available on the recovery rate and risk
factors associated with permanent, rather than transient
nerve injury.13 Inferior alveolar sequelae are associated
with a risk of permanent consequences less than 1% of
the time, whereas the lingual nerve presents permanent
The specific aims of this study were to (1) analyze
the prevalence of neurological lesions after third molar
extractions; and (2) correlate nerve injury with radio-
graphic findings, surgical procedure, and the third mo-
lar–related pathology that indicated extraction.
MATERIALS AND METHODS
The study was designed as a retrospective cohort
study of neurological complications after third molar

e8
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Volume 107, Number 2
extraction under general anesthesia. There were no
exclusion criteria. The clinical records of 183 patients
(median age 28, I quartile 22, III quartile 39; 81 males,
74 females) from 2002 to 2005 were analyzed to iden-
tify correlations between surgical procedure, third mo-
lar–related pathology, and permanent or temporary
neurological involvement.
A total of 408 third molars (165 upper and 243
lower) were extracted at the Oral Surgery Unit of the
Dental Clinic of the University of Trieste, Italy.
The same operator performed all the extractions us-
ing general anesthesia and standardized surgical instru-
ments and procedures. When necessary, for totally or
partially impacted upper and lower molars, a buccal
total thickness trapezoidal flap was raised. Accurate
periosteal elevation was made, particularly on lingual
zone. The lingual flap was protected using a lingual
retractor during all the surgical procedures (ostectomy,
tooth sectioning, and luxation) to preserve soft lingual
tissues and the lingual nerve that is often localized near
the inferior third molar, a few millimeters distally and
lower with respect to the second molar and leveled with
or superior to the crest of the lingual plate.14 Ostectomy
and tooth sectioning were performed using diamond or
Allport burs inserted on low-speed handpiece (30,000
rotations/minute), always irrigated with sterile saline
solution. Sutures were polyglactin threads (Vicryl), tak-
ing care not to pass the suture deeply in the lingual zone
and trap the lingual nerve in the suture. A recent study
in fact reported that involved nerves were always found
trapped in scar tissue and sometimes expanded to form
a neuroma.15
Antibiotic and anti-inflammatory medications were
prescribed (usually amoxicillin 1 g intravenously dur-
ing surgery and orally on subsequent days, 2 times
daily for 5 days when necessary and ketorolac 30 mg
intravenously during recovery when necessary), with
0.2% chlorhexidine rinses 2 times a day for 7 days.
The following data were collected from the clinical
records of all patients: Pell and Gregory class, degree of
inclusion (erupted, mucosal retention, or bone reten-
tion), pathology justifying the extraction (disodontiasis
with recurrent pericoronal infection, periodontitis, mu-
cosal trauma, caries, involvement of contiguous teeth,
abscess, orthodontic reasons), and surgical technique
(flap preparation, osteotomy, and tooth sectioning).
Moreover, the presence of permanent or temporary
neurological complications (hypoesthesia, paresthesia,
anesthesia) occurring after the extraction were studied,
classifying lesions as temporary if they resolved in 6
months. Neurological involvement longer than 6
months was considered to be permanent, as it has been
observed that the probability of recovery beyond 6
months is very low.16
Costantinides et al. e9
Table I. Subdivision of elements following radio-
graphic classification
Pell and Gregory classification No. elements (n ⫽ 408)
Upper molars n ⫽ 165
A 104 (63%)
B 34 (21%)
C 27 (16%)
Lower molars n ⫽ 243
IA 89 (37%)
IIA 40 (16%)
IIIA 3 (1%)
IB 22 (9%)
IIB 50 (21%)
IIIB 2 (1%)
IC 14 (6%)
IIC 7 (3%)
IIIC 16 (7%)
Continuous variables are presented as medians (first
and third quartile in squared brackets). Categorical
variables are presented as an absolute number (percent-
age in round brackets). The individual effect of clinical
data on the presence of paresthesia was evaluated by a
logistic regression model. All variables considered
were entered into the model “as is,” ie, without any
transformation or cutting off. Selection criterion was
the AIC (Akaike Information Criterion) applied back-
ward for each model tested. The final model was se-
lected if superior in terms of AIC at a significance level
of .05. Because data were modeled as teeth and not
subjects, all estimates and the relative confidence
bounds and significance tests were adjusted using the
Huber-White sandwich estimator.17 Statistical signifi-
cance was set at a P value less than .05 and indicated if
less than .25; otherwise the “NS” indication was used.
The S-plus (release 2000) statistical package and the
Harrell’s Design and Hmisc libraries were used for
analysis.
RESULTS
The Pell and Gregory classification considers
classes I, II, and III and A, B, and C based on the
position of the inferior third molar with respect to the
mandibular bone and second molar occlusal plane.
Upper molars are classified as belonging to class A,
B, or C with respect to second molar occlusal plane.
Table I shows the extracted teeth divided following
this classification.
Table II presents the motivations or the pathology
related to the third molars extracted and the surgical
techniques applied. A total of 324 elements (80.4%)
were removed because of disodontiasis; 69 teeth
(17.1%) for chronic periodontitis.
Regarding the surgical procedure, 289 teeth (71.2%,
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e10 Costantinides et al. February 2009

Table II. Subdivision of elements following preopera- At multivariable analysis, only the variable “ab-
tive and surgical variables scess” was found to be significantly related to pares-
No. elements (n ⫽ 408) thesia (odds ratio [OR] 6.86; 95% confidence interval
Upper molars Lower molars [CI] 1.21-38.8; P ⫽ .029).
(UM) (LM)
Variables (n ⫽ 165) (n ⫽ 243)
DISCUSSION
Indications for third molars
Nerve involvement is a rare but serious complication
extraction, n (%)
Disodontiasis 128 (78) 196 (81) of third molar surgery. The 4 most common postoper-
Periodontitis 23 (14) 46 (19) ative complications reported in the literature are alve-
Mucosal traumatism 13 (8) 3 (1) olar osteitis, infection, bleeding, and paresthesia.18
Caries 11 (7) 10 (4) Miller et al.19 indicate that nerve dysfunction is the
Involvement of 0 (0) 0 (0)
third most common complication after alveolar osteitis
contiguous teeth
Abscess 3 (2) 7 (3) and postoperative infections with an approximate inci-
Orthodontic motivations 4 (2) 3 (1) dence of 0.57% to 5.30%.
No pathology 0 (0) 0 (0) Several studies have identified etiologic factors as-
Surgical technique, n (%) sociated with nerve injury, such as age of the patient,
Simple extraction 86 (52) 33 (14)
radiographic findings, and surgeon experience.1,8,20,21
Flap 79 (48) 210 (86)
Ostectomy 36 (22) 186 (77) Regarding surgical technique, the lingual split tech-
Tooth sectioning 11 (7) 124 (51) nique and other techniques have been introduced to
reduce the prevalence of nerve injury.
Our results show a total prevalence of neurological
involvement of 6.1% (5.8% considering temporary in-
juries only) without any case of permanent inferior
79 upper and 210 lower) needed flap preparation; 222 alveolar damage (0.0%) and only one case of perma-
cases (55.1%, 36 upper and 186 lower) needed ostec- nent (⬎ 6 months) lingual nerve lesion (0.3%). These
tomy, and 135 cases (33.5%, 11 upper and 124 lower) findings are in agreement with previous reports. Gomes
needed tooth sectioning. et al.22 studied a sample of 55 patients operated for
After surgery, neurological involvement affected 13 third molar removal under local or general anesthesia.
patients for a total of 15 extracted molars (6.1%). The authors found that the percentage of sensory dis-
Fourteen cases reported temporary lesions and 1 patient turbance was higher among patients treated under gen-
reported a permanent lesion. In total, 10 cases regarded eral/local anesthesia (13.8%) than among patients op-
the ipsilateral inferior alveolar nerve, 4 cases the ipsi- erated under local anesthesia (3.8%). Brann et al.23
lateral lingual nerve, and 1 case both the ipsilateral found that lingual and inferior nerve damage was 5
inferior alveolar and the lingual nerve. No permanent times more frequent when lower third molars were
injuries to the alveolar inferior nerve were found (0%). removed under general anesthesia than under local an-
Only one case presented a permanent lesion affecting esthesia. Comparable results were obtained by Rehman
the ipsilateral lingual nerve (0.3%). Patients presenting et al.24 who found an incidence of lingual and inferior
temporary neurological complications had as an indi- alveolar nerves injuries of 0.65% and 0.80%, respec-
cation/motivation for extraction disodontiasis (12 tively, with a local block, but 3.58% and 3.26% under
cases), periodontitis (1 case), or abscess (1 case); the general anesthesia.
patient with the temporary alveolar lesion associated However, the small number of cases of paresthesia
with permanent lingual lesion presented a disodontiasis limits the generalization of results regarding its associ-
(1 case). Eleven patients needed flap preparation, os- ation with the considered risk factors. Nevertheless, if
tectomy, and tooth sectioning; 3 patients needed flap taken as a preliminary finding of an uncontrolled, ex-
preparation associated with ostectomy; and 1 patient ploratory study, the multivariate model indicates that
required flap alone (Table III). radiological classification and surgical difficulty are not
The permanent lingual lesion was observed in a variables that influence the prevalence and severity of
28-year-old patient who presented at the Dental Clinic neurological lesions. Only the variable “abscess” is
because of an odontogenic abscess, with third inferior correlated with a higher risk of permanent nerve inju-
molar belonging to Pell and Gregory class I-A. The ries (OR 6.86). Abscesses are infectious-inflammatory
surgical approach required only flap preparation with- conditions often associated with the altered eruption of
out ostectomy or sectioning. third molars. However, few cases in the literature have
Relations between neurological involvement and in- correlated infectious conditions of dental origin with
clusion class are reported in Table IV. nerves injuries.
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Volume 107, Number 2 Costantinides et al. e11

Table III. Clinical details of the observed paresthesiae

Pell and Gregory Pathology correlated Surgical Neurological
Patient class to third molar technique involvement Duration
4 IA Disodontiasis F; TS; OT IAN T
20 II B Disodontiasis F; TS; OT IAN T
26 II B Disodontiasis F; TS; OT IAN T
26 II B Disodontiasis F; TS; OT IAN T
34 IA Abscess F L P
64 IA Disodontiasis F; TS; OT L T
65 IC Disodontiasis F; TS; OT L ⫹ IAN T
94 IB Disodontiasis F; OT IAN T
97 II B Periodontitis F; TS; OT IAN T
100 IA Disodontiasis F; OT IAN T
100 II A Disodontiasis F; TS; OT IAN T
138 IB Disodontiasis F; TS; OT L T
154 III C Disodontiasis F; TS; OT IAN T
164 II B Disodontiasis F; TS; OT IAN T
180 II A Disodontiasis F; OT L T
F, flap; TS, tooth sectioning; OT, ostectomy; IAN, inferior alveolar nerve; L, lingual; T, temporary; P, permanent.

Table IV. Characteristics of the study sample in relation to the presence of paresthesia and overall
No. cases without No. cases with
paresthesia paresthesia Combined
N (N ⫽ 228) (N ⫽ 15) (N ⫽ 243) P value
Age 243 23/28/37.25 24.50/28/32 23/28/37 .9396
Gender: M 243 49% (111) 47% (7) 49% (118) .8797
PELL-GREGORY : I-A 243 37% (84) 27% (4) 37% (89) Ref*
I-B 9% (20) 13% (2) 9% (22) .4028
I-C 6% (13) 7% (1) 6% (14) .6710
II-A 17% (38) 13% (2) 16% (40) .8997
II-B 20% (45) 33% (5) 21% (50) .2169
II-C 3% (7) 0% (0) 3% (7) .8531
III-A 1% (3) 0% (0) 1% (3) .9035
III-B 1% (2) 0% (0) 1% (2) .9212
III-C 7% (15) 7% (1) 7% (16) .7625
Flap: yes 243 86% (196) 93% (14) 86% (210) .4322
Ostectomy: yes 243 76% (173) 87% (13) 77% (186) .3491
Tooth sectioning: yes 241 50% (114) 67% (10) 51% (124) .2308
Altered eruption: yes 243 81% (184) 80% (12) 81% (196) .9469
Abscess: yes 243 2% (5) 13% (⬎2) 3% (7) .0294
Orthodontic treatment: yes 243 1% (3) 0% (0) 1% (3) .8593
Caries: yes 243 4% (10) 0% (0) 4% (10) .8135
Chronic periodontitis: yes 243 19% (43) 20% (3) 19% (46) .9131
Mucosal trauma: yes 243 1% (3) 0% (0) 1% (3) .8593
Right-Left:Left 243 52% (119) 53% (8) 52% (127) .9318
Paresthesia Localization: lingual 15 33% (5) 33% (5)
Paresthesia type: temporary 15 93% (14) 93% (14)
Continuous variables are presented as median (first and third quartile in squared brackets). Categorical variables are presented as absolute numbers
(percentage in round brackets).
*Reference category.

Di Lenarda et al.25 and Giuliani et al.26 underline that
infectious processes in the mandible may result in par-
esthesia. The authors found a direct correlation between
a periapical abscess and inferior alveolar nerve lesion,
considering that tissue metabolism and bacterial toxins
may involve nervous fibers through a compressive
mechanism. Moreover, Giuliani et al.26 hypothesize
two pathogenetic phases: initially, drainage of purulent
exudate could directly damage the myelin sheath with
reversible sequelae, then infection could heal with a
residual fibrotic– cicatritial reaction causing irreversible
damage to the nerve. Clinical correlations with this

e12 Costantinides et al.
pathological finding are not known. In particular, it is
not clear whether acute involvement of the sheath or
cicatritial tissue reaction following the abscess are as-
sociated with clinically evident paresthesia or a sub-
clinical condition.
Our data show that a patient with recurrent infection
associated with a lower wisdom tooth has about a 7
times higher risk of manifesting clinically evident nerve
paresthesia. For this reason it may be hypothesized that
repetitive infections, histologically but not clinically
evident, increase the susceptibility of nerve sheaths to
surgical events (fibrous tissue formation between the
tooth and nerve sheath) so that surgical traction or
pressure movements load indirectly on the nerve fibers.
Microscopic evaluations are necessary to confirm this
hypothesis.
The permanent lesion involved only the lingual nerve
in a 28-year-old subject who needed flap preparation
alone for tooth extraction. It is known that the lingual
nerve is not identifiable on conventional radiograms so
that a precise evaluation of its anatomic course for
surgical planning is not possible.
Several studies have reported that since the 1980s
there has been no significant decrease in the incidence
of lingual nerve damage, with temporary involvement
ranging from 0% to 22% and permanent damage rang-
ing from 0% to 2% of all lower third molars re-
moved.27,28 This last percentage represents a fixed
value that does not decrease and that seems not to be
correlated with the surgical technique, third molar-
related pathology, or advanced age. Pogrel et al.,14
using a specific lingual retractor in 250 patients, did not
find any permanent lesion of the lingual nerve but a rate
of lingual paresthesia of 1.6%. However, the same
authors stated that a previous meta-analysis, performed
by Pichler and Beime in 2001, had failed to show any
difference in permanent lingual nerve injury rates
whether a lingual retractor was used or not.14,29
Explanation of this phenomenon has to be researched
in lingual nerve anatomical variables that cannot be
analyzed radiographically. Consequently, if there were
been codify several radiographic signs to evaluate con-
tiguity between third molars and inferior alveolar nerve
(darkening of the root, interruption of the white line,
diversion/displacement of the inferior alveolar canal,
deflected roots, narrowing of the root) it is not possible
to identify lingual nerve position with conventional
radiology.8
It appears clear that additional exams (magnetic res-
onance or computerized) have to be introduced in clin-
ical practice to localize the lingual nerve and its conti-
guity to third molars. A careful analysis of the risk-
benefit ratio is required to assess the biological and
economic implications of this approach.
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February 2009
CONCLUSION
Analysis of surgical variables is important to under-
stand and reduce nerve damage after oral surgery. Fur-
ther studies are necessary to:
- explain the importance of each variables (patient-
correlated, tooth-correlated, operator-correlated) on the
prevalence and severity of nerve injuries;
- evaluate whether lingual and alveolar nerve histo-
logical features could explain the increased paresthesia
risk in infectious-inflammatory events;
- ascertain whether the use of nonconventional radi-
ology could reduce the percentage of damaged nerves.
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Reprint requests:
Fulvia Costantinides, DDS
via Stuparich 1, 34100
Trieste, Italy
f.costantinides@fmc.units.it;
fulviacostantinides@hotmail.com