Presented by : Cita Darmastuti

The surgical removal of impacted mandibular

third molar : Pain, swelling, bruising, trismus Sometimes lingual nerve damage

This complication is usually unexpected and unacceptable for the patients

 Incidence of lingual nerve injury, because of Surgeon`s unexperience

Procedure

methodology and certain specific factors such as raising and retracting a lingual mucoperiosteal

 Amongst the most studies, causes of the

lingual nerve damage : Lingual plate perforation Lingual flap trauma during ostectomy or tooth sectioning Usage of lingual flap retractor Supra crestal incision

 Pogral and Miloro, Kiesselback intimate

relationship between the lingual nerve and mandibular lingual plate around posterior areas.
Manson no single factor to be causative

but the most significant were the depth of impaction, removal of distal bone, elevation of lingual flap and length of operation time.

 Aim :

To determine the clinical incidence of lingual nerve injury following mandibular third molar removal and to analyze possible etiologic factors for the lingual nerve injury.

 90 patients, from january december 2009

for surgical removal of impacted mandibular third molar. Pre operative factors, such as depth of impaction, tooth position and bony coverage The impacted classified by the winter`s classification.

Local anesthesia

Bone removal (motor driver surgical bur, constant irigation of normal saline)

The same operator

Gutter in the disto buccal bone

The standart Terence Ward`s incision

Reflecting the buccal flap

 Sensory disturbance on 1st and 7th post

operative day. Complaint concerning sensory disturbance of the lingual gingiva and mucosa of the floor of the mouth and tongue. Assesment of post operative do you have normal feeling in your tongue?, and pin prick tes.

Patient

observed up to 6 months.

any complaint sensory disturbance on postoperative evaluation

at the interval of one month,

advised for regular follow up

 6 patient were diagnosed with lingual nerve

paraesthesia on 1st and 7th post operative day evaluation (6,6%) 1 patient lost from the study after 3 month of observation geographical relocation. 1 patient paraesthesia persisted even after 6 months cyanocobalamin 1.500 unit/ day.

 4 patients recovered within 6 months of

observation.
paraesthesia horizontal and distoangulation of impaction,

impaction with the crown approximating the

CEJ of second molar, lingual inclination of tooth, state of eruption and duration of surgery.

Table 1 : number of patients with paraesthesia, tooth position, depth of impaction, state of eruption and time of recovery
patient tooth Paraesthesia area Position of tooth Depth of impaction Bucco-lingual inclination State of eruption Time of resolution of paraesthesia

1 2 3

48 38 48

Right side of tongue Left side of tongue Right side of tongue

Distoangular Distoangular Distoangular

Level 2 Level 1 Level 3

Buccally No inclination Lingually

Incomplete bone cover Partially erupted Complete bone cover

2 months 1 months No resolution up to 6 months 3 months 5 months 4 months

4*
5 6

48
38 38

Right side of tongue

Left side of tongue Left side of tongue

horizontal
mesioangular mesioangular

Level 2
Level 3 Level 3

No inclination Lingually
lingually

Incomplete bone cover Complete bone cover Complete bone cover

* Patient with paraesthesia was lost from the study after approximately 3 months of observation due to geographical relocation

 This study supports other retrospective report

(David T. Wofford) a possible association between paraesthesia and bony impacted mandibular third molars, use of bur to remove bone during the surgical extraction, position of impaction and state of eruption.

The causative factors can be discussed under following headings :

1. Lingual inclination and lingual flap

ratraction Lingual retractor was not used in any case Pichler JW, Beirne lingual nerve injury is 8.8 time more likely to occur in buccal approach without lingual retractor Pogrel et al and Green wood et al the lingual flap reflection and use broader retractors to protect the lingual nerve

 15 patient in which third molar was lingually

inclined the lingual tissue was retracted only to expose the occlusal aspect of tooth. Out of these 15 patients, 3 patient with paraesthesia : 2 patients resolved within 5 months. 1 patient didn`t resolve even within 6 months follow up.

Incidence of lingual nerve paraesthesia was more observed with lingually inclined tooth than buccal inclination

Table 2 : buccolingual inclination and paraesthesia

Buccolingual inclination No. Of patients Patient with paraesthesia

Buccal inclination Lingual inclination No inclination

45 15 30

2 (4.4%) 3 (20%) 1 (3.3%)

2. State of eruption Valmeseda-Castellon incidence of

lingual nerve paraesthesia was more prone on surgical removal of unerupted mandibular third molar. This study observed more lingual nerve paraesthesia with surgical removal of unerupted mandibular (complete bone cover) third molar.

Table 3 : state of eruption and paraesthesia

State of eruption No. Of patient Patient with paraesthesia

Partially erupted Unerupted Soft tissue cover Incomplete bone cover Complete bone cover

63 (27) 7 12 8

1 (1.58%) 0

2 (16.6%) 3 (37.5%)

3. Tooth position 5 patients (horizontal-impacted)

odontotomy with slight distal bone cutting as needed in these cases and we found postoperative paraesthesia in one patient.
The distal ostectomy may be causative factor for paraesthesia in this patient (ValmesedaCastellon)

Table 4 : tooth position and paraesthesia

Tooth position No. Of patients Patients with paraesthesia

Mesioangular Horizontal Vertical Distoangular

40 5 30 15

2 (5%) 1 (20%) 0 (0) 3 (20%)

4. Depth of impaction Third molar present below the CEJ of

second molar (level 3) is more significant for paraesthesia. D. A. Mason 2005 the depth of impaction is significantly related with lingual nerve injury.

Table 5. : depth of impaction and paraesthesia

depth No. Of patients Patients with paraesthesia

Position A Position B Position C

38 25 27

1 (2.6%) 2 (8%) 3 (11.1%)

5. Operation time Paraesthesia in one patient seemed to be

`permanent`, the tooth was placed distoangular and completely covered with bone almost 40 min. Other patient average time of removal was 20 min. Valmeseda-Castellon the surgical time may be a contribute for lingual nerve injury

Zuniga, JR, Blackburn CW the incidence of permanent damage of lingual nerve vary between 0.5% to 2% this study 1.1% Conclusion lingual nerve paraesthesia can occur with or without reflection of lingual flap and in spite of all the measures taken to protect it. It may be contributed to the fact of anatomical variations of lingual nerve. Lingual nerve can be injured during surgical procedure, it should be well explained to the patient to avoid any legal litigation.