O R A L S U R G EO R A L

R Y S U R G E R Y

Nerve Damage and Third Molar

Removal
A. R. LOESCHER, K. G. SMITH AND P. P. ROBINSON

connective tissue and other structures in

Abstract: The surgical removal of lower third molars endangers both the lingual and the neurovascular bundle. After injury,
inferior alveolar nerves. Patients sustaining an injury to either of these nerves must be
unless the nerve is displaced into the
managed correctly, and this requires a diagnosis of the injury type and regular
monitoring of the recovery of sensation. Surgical intervention for a damaged inferior
socket, the severed nerve ends do not
alveolar nerve is not usually indicated but may be undertaken: if the nerve is retract, but will remain in apposition.
completely divided and the severed ends are misaligned; if a bony fragment has Regeneration within the canal will thus be
compressed the mandibular canal; or if the patient suffers from persistent neuropathic unimpeded unless obstructed by
pain. In contrast, after injury to the lingual nerve, if sensory testing demonstrates no displaced fragments of bone from the
neural recovery within 3–4 months, exploration of the injury site and microsurgical roof of the canal. Good recovery after
repair of the damaged nerve is indicated. injury would therefore be expected.
Many studies have reported the
Dent Update 2003; 30: 375–382 frequency of nerve injury during the
Clinical Relevance: It is imperative that patients sustaining a nerve injury are removal of third molars (for review see
managed correctly and this must include a diagnosis of the type of injury, monitoring Robinson 19971) and most indicate that
recovery and the treatment of appropriate cases. inferior alveolar nerve function is
disturbed after 4–5% of procedures
(range 1.3–7.8%). Most patients will
regain normal sensation within a few
weeks or months and less than 1% (range
I mpacted mandibular third molar teeth
are in close proximity to the lingual,
inferior alveolar, mylohyoid and buccal
speech and mastication and may
adversely affect the patient’s quality of
life. They also constitute one of the most
0–2.2%) have a persistent sensory
disturbance.
nerves (Figure 1). During surgical frequent causes of complaints and The anatomical relationship between
removal, each of these nerves is at risk of litigation. It is therefore imperative that
damage, but the most troublesome patients sustaining nerve injuries are
complications result from inferior alveolar managed correctly, and this includes
or lingual nerve injuries. The majority of correct diagnosis of the type of injury,
injuries result in transient sensory monitoring recovery, and the treatment of
disturbance but, in some cases, appropriate cases.
permanent paraesthesia (abnormal The characteristics of the inferior
sensation), hypoaesthesia (reduced alveolar, lingual and buccal nerves, and
sensation) or, even worse, some form of the likely incidence of damage, will now
dysaesthesia (unpleasant abnormal be discussed. Injury to the mylohyoid
sensation) can occur (Table 1). These nerve is rare and is not considered further
sensory disturbances can be in this brief update.
troublesome causing problems with

INFERIOR ALVEOLAR NERVE

A.R. Loescher, BDS, PhD, FDS RCS, MBChB,
K.G. Smith, BDS, PhD, FDS RCS and The inferior alveolar nerve is
P. P. Robinson, BDS, PhD, FDS RCS, DSc, FMedSci, morphologically unusual in that it travels
Department of Oral and Maxillofacial Surgery, a significant distance within bone in the
School of Clinical Dentistry, Claremont Crescent, Figure 1. Cross-section of the mandible through
mandible. In the mandibular canal it is the third molar showing the inferior alveolar,
Sheffield S10 2TA.
supported by the surrounding lingual, mylohyoid and long buccal nerves.

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 O R A L S U R G E R Y

In addition to the surgical technique,

Anaesthesia Absence of all sensory modalities.
other risk factors have been identified.
Hypoaesthesia Diminished sensitivity to stimulation, excluding special senses. Lingual nerve damage is particularly
associated with deeply impacted teeth
Paraesthesia An abnormal sensation, whether spontaneous or evoked.
when the surgery is consequently
Dysaesthesia Unpleasant abnormal sensation, whether spontaneous or evoked. difficult, particularly if distal bone
removal is required.9,10 The results of
Hyperalgesia An increased response to a stimulus that is normally painful.
studies comparing the incidence of
Allodynia Pain due to a stimulus that does not normally provoke pain. lingual nerve injury during surgery
utilizing bone removal with burs or
Table 1. Pain terms adapted from the definitions of the International Association for the Study of Pain
(www.iasp-pain.org). chisels are unclear.9,10 It is possible that
the elevation of a lingual mucoperiosteal
flap when chisels are utilized is of more
the inferior alveolar nerve and the roots trapped or constricted by scar tissue. importance than the method of bone
of the third molar may be judged Regeneration of axons across a gap will removal itself. A recently published
radiographically2,3,4,5 in an attempt to be less successful than if the nerve ends prospective study undertaken by Renton
predict the likelihood of nerve damage. remain in apposition. In addition, the and McGurk14 reported that factors
Rood and Shehab (1990)5 identified five presence of a range of functionally reflecting the surgical skill (i.e. lingual
radiographic features that were related to distinct nerve fibre types in this nerve plate perforation) and the difficulty of the
inferior alveolar nerve injury and these (e.g. mechanosensitive, thermosensitive, extraction were the strongest predictors
are listed in Figure 2. The same study gustatory, vasomotor and secretomotor) of temporary and permanent lingual nerve
failed to show that ‘narrowing of the may make successful regeneration of the injury.
inferior alveolar canal’ and the ‘presence axons back to the correct receptor/
of a dark and bifid apex’ were significant effector and location less likely (see
predictors of inferior alveolar nerve below). BUCCAL NERVE
injury; features that had previously been There is a wide range in the reported This nerve descends between the two
considered important.6 Paradoxically, frequency of lingual nerve injuries during parts of the lateral pterygoid muscle,
sensory disturbance may occur following third molar removal, with 0.2–22% of medial to the ramus of the mandible, and
removal of teeth that show none of these patients reporting sensory disturbances then passes laterally across the external
features, and may not occur even when in the early post-operative period and 0– oblique ridge distal to the third molar, to
there appears to be clear evidence of a 2% a permanent disturbance (for review supply the cheek.15 The sensory
close relationship between the canal and see Robinson 19971). There are several distribution is variable but includes the
the tooth roots. possible explanations for the wide range lower posterior buccal sulcus and
A higher incidence of inferior alveolar in incidence. First, the variation may
nerve injury has been reported with third reflect differences in the time interval
molars that are horizontally3,7 or between tooth removal and the
mesioangularly4 impacted and have assessment of the sensory impairment;
complete bone cover.7 One study has early assessments will report many
also demonstrated that increasing age is transient sensory changes that recover
associated with a higher frequency of rapidly and completely, and which would
inferior alveolar nerve injury (14–24 year- be missed if assessment takes place after
old patients 1.2%; 35–81 year-old a longer recovery period. Secondly, the
patients 9.7%).8 incidence of nerve injury may depend
upon whether the sensory deficit was
established objectively by the clinician or
LINGUAL NERVE was based on a subjective patient
The lingual nerve is morphologically very assessment. Finally, it may reflect
different from the inferior alveolar nerve. differing surgical techniques; several
Figure 2. Five radiographic signs suggesting
At the usual site of injury (adjacent to the studies have shown that the raising and juxtaposition of the mandibular canal to the third
lower third molar) the nerve is covered retraction of a lingual mucoperiosteal flap molar roots, as described by Rood and Shehab
with only a thin layer of soft tissue and is associated with an increased frequency 1990.5 Signs significantly related to nerve injury:
mucosa, rather than being in a bony of lingual nerve damage.9,10 Two recent A. Radiolucency across the roots of the third
canal. Consequently, if sectioned, the cut studies and a systematic review have molar; B. Deviation of the mandibular canal; C.
Interruption of the white line of the canal. Signs
nerve ends retract apart and, if the concluded that raising and retracting a considered to be clinically important: D.
adjacent soft tissue is also distorted, the lingual periosteal flap is not necessary11 Deflection of the third molar roots by the canal; E.
nerve ends may become misaligned and and is best avoided.12,13 Narrowing of the third molar root.

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 O R A L S U R G E R Y

classification is valuable as it emphasizes segmental demyelination, but these

the importance of each structural changes are reversible.21 Recovery of
component of the nerve trunk (Figure sensation normally occurs within a few
3).21 Each of the five degrees of nerve days of the surgical trauma, although
injury, described by Sunderland, may be recovery may be slightly slower if
created during the removal of an segmental demyelination takes place.23
impacted third molar tooth: The cellular events that follow axonal
l Compression injuries (Figure 3A) discontinuity (2nd to 5th degree injuries)
may occur during the elevation of a have been studied extensively21,24 and are
third molar with roots in close summarized in Figure 4. Wallerian
proximity to the mandibular canal. degeneration occurs distal to the site of
Minor compression of the nerve, or the injury and usually extends centrally
first degree injuries, will give rise to for a few millimetres.25 This axonal
a temporary conduction block, which degeneration consists of disintegration
is referred to by Seddon19 as of both the axon and myelin,
neurapraxia. phagocytosis of the debris by the
l More severe compression or crush macrophages and Schwann cells, and
injuries (Figure 3B) cause the axon
distal to the site of the injury to
degenerate (Wallerian degeneration)
and recovery of sensation is
dependent upon regeneration of the
Figure 3. Sunderland’s classification of the five damaged axons. Seddon19 refers to
degrees of nerve injury. A. Conduction block; B. this second degree injury as
Transection of the axon with an intact axonotmesis.
endoneurium; C. Transection of the nerve fibre
l Stretch injuries could occur, for
(axon and endoneurial sheath) inside an intact
perineurium; D. Transection of nerve fibres and example, when raising a lingual
perineurium, nerve trunk continuity being mucoperiosteal flap, and could give
maintained by epineurial tissue; E. Transection of rise to rupture of the endoneurium
the entire nerve trunk. Modified from and perineurium to produce third or
Sunderland.21
fourth degree injuries (Figures 3C
and D), respectively.
gingivae, and an area of cheek mucosa.16 l Complete section of the nerve trunk
As the nerve crosses the external oblique or fifth degree injuries (Figure 3E),
ridge it is composed of between one and referred to by Seddon19 as
five branches, the lowest of which may neurotmesis, may occur if the inferior
be over 1 cm below the deepest alveolar nerve penetrates the root of
concavity of the ridge.17 Therefore, part a third molar and is severed during
or all of the nerve is at risk when the tooth removal.
distal relieving incision is made during l Many nerve injuries that do not fit
third molar surgery. Small areas of neatly into this classification and are Figure 4. A diagrammatic representation of the
sensory disturbance may go unnoticed18 more complicated. For example, a cellular events which follow axonal discontinuity
but a few patients complain of complete rotating bur may not only partially of a myelinated trigeminal nerve fibre. A. Normal
appearance. B. Transection of the nerve fibre
anaesthesia of the cheek; the incidence divide the lingual nerve but also peripherally results in distal fragmentation of the
of this complication has not been stretch the nerve. Inflammation axon and the myelin. In the proximal segment
reported. around the nerve, caused by degeneration occurs to at least the first node of
infection or foreign bodies, may also Ranvier. C. Schwann cells in the distal stump
alter neural function and increase the form the bands of Büngner through which the
CLASSIFICATION OF NERVE axon sprouts regenerate. D. The regenerated
pain experienced.22 axon regains contact with the periphery and
INJURY matures, but a reduction in diameter persists. E. If
The consequences and subsequent the cut ends of the nerve are widely separated, it
recovery following nerve damage are SEQUELAE OF NERVE is less likely that good recovery will occur and
dependent upon the severity of the INJURY abnormalities may persist. Sprouts may locate
and innervate inappropriate targets or, if no
injury, and this is the basis for the Temporary block of nerve conduction target organ is located, axonal sprouts may
classifications of nerve injury proposed (1st degree injury) may be accompanied persist as a neuroma.Modified from Holland and
by Seddon19 and Sunderland.20 The latter by some local thinning of the axons and Robinson.24

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 O R A L S U R G E R Y

then proliferation of the Schwann cells However, careful monitoring of sensory

within the endoneurial sheath to form the recovery over a three month period
bands of Büngner. Central to the site of should distinguish between these
the injury, the rest of the neurone different types of injury.
undergoes chromatolytic changes from Monitoring sensory recovery is
which it may or may not recover. undertaken by the application of stimuli
Regeneration of the axons that survive to the denervated area. Responses of the
occurs after an initial delay, which patient will indicate first the arrival of the
includes a recovery period and the time regenerating axons and then
needed for growth of the axon as far as subsequently the level of recovery.
the injured zone. There is then a delay However, the most sensitive indicator of
during which the regenerating fibres a sensory abnormality is the patient’s
cross the injured zone. The initial delay own subjective report, as minor sensory
prior to regeneration, and the success of disturbances may not be detected by
axons in crossing the injury site, is testing.
dependent upon the nature of the injury.
Crush injuries will recover more rapidly
than section injuries as the endoneurial Simple Sensory Testing
sheaths usually remain intact and A standard protocol for sensory testing
therefore the regenerating axons are does not exist, but a series of simple tests
guided back to the correct receptor type are outlined below. The patient should be
at the correct location.26 In contrast, after seated in a quiet room with both the
nerve section injuries, the regenerating patient and examiner comfortable. Tests
axons enter the endoneurial sheaths of should be undertaken with the patient’s Figure 5. An instrument used to apply pin prick
stimuli with calibrated pressures of up to 150mN
the distal stump, apparently at random, eyes closed and the detection of a
(15g).
and may be guided to an inappropriate stimulus is indicated to the examiner by
receptor at a new location. This may give the patient raising a finger. The results of
rise to abnormalities in localization and each test are then compared with the performed using a dental probe or needle,
the sensation perceived in response to a normal (uninjured) side. Ideally, the first but again reproducibility is poor. A
particular stimulus. Recovery from crush sensory tests should be undertaken simple device, described by Sunderland,21
injuries may take months and may not be within two weeks of the injury in order to overcomes this difficulty. A pin is
complete. Recovery from nerve section establish a base-line from which to attached to a spring, which allows it to be
injuries will progress for at least a year monitor changes. Unfortunately, the applied at a known pressure of up to 150
and will never be complete. equipment needed to perform some of mN (15 g) (Figure 5). Initially, stimuli of
these tests is not readily available and up to 150 mN can be applied randomly
must be constructed by individual over the test areas to determine whether
METHODS USED TO clinicians.27 or not any sensation is perceived. In this
MONITOR NERVE way, areas of anaesthesia can be mapped.
RECOVERY Light Touch Sensation If sensation is present within the affected
Most cases of nerve damage during Light touch is most commonly tested by area on the injured side, then the pin
wisdom tooth removal are not identified gently applying a wisp of cotton wool to prick sensation threshold is determined.
at the time of third molar removal but in the skin or mucosa. However, it is difficult For this test the pin is applied at steadily
the post-operative period. The degree of to apply this stimulus in a reproducible increasing pressures and the patient
injury is therefore unknown and it is manner and the use of a cotton wool wisp asked to indicate the point at which the
essential both to assess residual function on moist oral mucosa is difficult. Greater sensation becomes sharp rather than dull.
and monitor subsequent recovery to form consistency and reproducibility can be The pin prick sensation threshold is
a judgement as to whether or not the obtained using Von Frey hairs and the noted for a series of randomly chosen
nerve is likely to recover spontaneously, method of making these instruments with points on both the injured and the
or if surgical intervention will be required. a standard force of 20 mN (2g) has been uninjured side.
If there is only partial sensory loss, this described.27 Stimuli are applied at random
usually suggests that there has been a and the area of anaesthesia can be Two Point Discrimination
first degree injury, and complete recovery mapped by moving outwards in small This test can quickly be performed if
is likely. If there is complete anaesthesia steps until the stimulus is felt. pairs of blunt probes with different
in the early period after the injury, it is separations (2–20 mm) are mounted
impossible to determine whether this has Pin prick sensation around a disc (Figure 6).27 The probes
been caused by a crush or section injury. Testing pin prick threshold is often are applied at a series of fixed sites

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 O R A L S U R G E R Y

Inferior alveolar nerve referral to an appropriate experienced

If an inferior alveolar nerve passes maxillofacial surgeon is indicated. In the
through the roots of a wisdom tooth and majority of patients, the injury is only
is accidentally divided at the time of discovered post-operatively.
surgery, repair is indicated if the nerve At early review, the presence of some
ends do not remain in apposition within sensation in response to stimulation of
the canal. This should ideally be the tongue suggests that the nerve is at
performed at the same time as the tooth least partially intact; no treatment is
removal, but if this is not possible the indicated but sensory monitoring is
patient should be referred urgently to an required. As described above, complete
appropriate maxillofacial unit. anaesthesia could be caused by both a
If a sensory disturbance is first noted crush or section injury, and so surgical
at review, recovery should be monitored intervention is not indicated initially.
using the sensory tests described above. However, the absence of progressive
Patients with paraesthesia in the sensory recovery by 3–4 months post
Figure 6. A simple device for rapid two point distribution of the inferior alveolar nerve injury is an indication for surgical
discrimination testing.
(evoked by touching the lip or chin) exploration at an appropriate maxillofacial
usually require no surgical intervention. unit. If, at the time of surgery, the nerve is
chosen on the lips or tongue, depending Patients with complete anaesthesia post- found to be intact and of fairly uniform
on which has been damaged. The probes operatively should be evaluated thickness but merely constricted by scar
are drawn a few millimetres across the radiographically to ensure that the roof of tissue, it should be freed (external
surface, at a constant pressure, and the the mandibular canal has not been neurolysis) and the wound closed. This
patient is asked whether one or two displaced inferiorly to create an is unusual, however, and more commonly
points are felt. The minimum separation, obstruction to regeneration.18 In the the nerve is found to have been
that is consistently reported as two extremely rare event that this has divided.29 If a neuroma has developed,
points, is termed the two point occurred, removal of the bony fragment this can be seen as a marked expansion at
discrimination threshold. This threshold would seem to be appropriate, without the site of the injury and must be excised,
varies in different regions of the mouth undue delay. Referral to a maxillofacial together with the damaged segment of
(2–4 mm on the tongue and lip, 8–10 mm surgeon familiar with this type of the nerve. The severed ends of the nerve
on the skin over the lower border of the procedure is important. The patient can then be mobilized and repair of the
chin). should also be informed that complete nerve should be performed using 8/0 or 9/0
recovery may not follow this procedure epineurial sutures. A segment of 10–15
Taste Stimulation and that some recovery may occur even if mm in length can be excised without
Lingual nerve injury will result in taste surgical ‘decompression’ is not causing excessive tension at the repair
loss from the ipsilateral anterior segment performed. site and without the need for any form of
of the tongue. Although taste testing If, by 3 months after the injury, nerve graft. The results of surgery are
may not be undertaken routinely, it is monitoring reveals little or no sensory very variable; some patients regain good
simple to perform. Cotton wool pledgets recovery, referral is again indicated. A sensation, while others show little if any
soaked in 1M sodium chloride, 1M further radiograph to assess the improvement. However, the multicentre
sucrose, 0.4M acetic acid or 0.1M continuity of the mandibular canal is retrospective study of LaBlanc & Gregg30
quinine are drawn 1–2 cm across the obtained, and surgical exploration and revealed a success rate of 80% and a
lateral border of the tongue and the ‘decompression’ of the nerve is recent prospective study has shown that
patient asked to indicate whether they considered if the canal is disrupted, if the majority of patients consider the
taste salt, sweet, sour, bitter or no taste, there is very little recovery of sensation, surgery worthwhile.29 Surgery should
before replacing the tongue in the or if there is significant dysaesthesia.28 therefore be offered to all patients with
mouth. Stimuli should be applied in However, the results of surgery are lingual nerve injury who show few signs
random order, to each side of the variable and sometimes disappointing. of spontaneous recovery.
tongue, and rinsing with tap water
between tests is permitted.

Lingual Nerve
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 O R A L S U R G E R Y

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