Review Article

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Inferior alveolar and lingual nerve injuries: an overview of

diagnosis and management
Fırat Selvi1, Nelli Yildirimyan2, John R. Zuniga3
1
Department of Oral and Maxillofacial Surgery, School of Dentistry, Istanbul University, Istanbul, Turkey; 2Department of Oral and Maxillofacial
Surgery, School of Dentistry, Medipol University, Istanbul, Turkey; 3Robert V. Walker DDS Chair in Oral and Maxillofacial Surgery, Department of
Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Contributions: (I) Conception and design: F Selvi, N Yildirimyan; (II) Administrative support: None; (III) Provision of study materials or patients: F
Selvi, JR Zuniga; (IV) Collection and assembly of data: F Selvi, N Yildirimyan; (V) Data analysis and interpretation: All authors; (VI) Manuscript
writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Dr. Fırat Selvi, DDS, PhD. Department of Oral & Maxillofacial Surgery, School of Dentistry, Istanbul University, Kalenderhane
Mah. Prof. Dr. Cavit Orhan Tutengil Sok. No. 4, Vezneciler/Fatih, Istanbul, Turkey. Email: fselvi@istanbul.edu.tr.

Abstract: Oral and maxillofacial surgery operations are susceptible to cause injury to terminal branches
of the trigeminal nerve. The mandibular division is more prone to injury than ophthalmic and maxillary
nerves. Inferior alveolar branch of the trigeminal nerve is the most commonly injured branch, followed
by the lingual nerve. These nerves may be subjected to neurosensorial disturbance during third molar
surgery, followed by sagittal split ramus osteotomy, endodontic therapy and dental implant placement. Local
anesthetic injections, pre-prosthetic surgery, various other types of orthognathic surgery, ablative tumor
surgery involving mandibular resections, osteoradionecrosis, osteomyelitis or maxillofacial trauma are among
other potential etiologic factors. If an inferior alveolar or lingual nerve injury occurs, a timely diagnosis and
a proper management are key factors to avoid further or permanent damage. A wide range of therapeutic
modalities are available in managing nerve injuries, ranging from simple observation to complex grafting,
depending on various factors. Data regarding nerve injuries may not always be reliable since most are based
upon personal experience and in a retrospective nature. It is also challenging to draw proper conclusions
from studies on nerve injuries due to the differences in outcome criteria and assessment methods. Still,
an accurate knowledge of anatomy should be combined with both clinical and radiological data to avoid
any nerve-related complications. Thus, this article will present a narrative review of the current literature
on the inferior alveolar and lingual nerve injuries, focusing on the functional assessment methods, factors
influencing recovery, the contemporary management protocols as well as future trends in nerve repairs.

Keywords: Lingual nerve injury; inferior alveolar nerve injury; neurorrhaphy; nerve repair; neurosensorial deficit

Received: 26 January 2021; Accepted: 26 June 2021; Published: 10 September 2022.

doi: 10.21037/fomm-21-8
View this article at: https://dx.doi.org/10.21037/fomm-21-8

Introduction first-degree injury corresponds with Seddon’s neuropraxia

and is the mildest form of injury. Second-, third- and
Nerve repair for an iatrogenic injury is evaluated separately fourth-degree injuries are parallel to axonotmesis and
for motor and sensory nerves, the former requiring urgent the fifth-degree, which is the complete transection of the
exploration and surgical intervention. On the other hand, nerve, is compatible with neurotmesis (2). The prognosis
injuries to sensory nerves are less time sensitive (1). for spontaneous recovery is inversely proportional to the
In 1951, Sunderland have proposed a classification for classification, meaning that excellent, good, fair, poor or
nerve injuries similar to the one of Seddon’s. Sunderland’s no recovery may be expected without any surgical repair

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Page 2 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

or approximation in injuries from first to fifth degrees, Materials and methods

respectively (3).
A comprehensive literature research was conducted using
Oral and maxillofacial surgical procedures are susceptible
PubMed database to identify studies published on inferior
to cause injury to terminal branches of the trigeminal nerve.
alveolar or LN injuries and their repair. The research
Although a vast majority of these injuries do not require
comprised the following keywords and Medical Subject
further intervention and undergo spontaneous neurosensory
Headings (MeSH) terms: [“lingual nerve” OR “inferior
recovery, they may sometimes result in serious functional
alveolar nerve”] AND [“nerve repair” OR “nerve injury”
deficits (4). Such cases have debilitating outcomes on
OR “management” OR “treatment”]. Among the resulting
orofacial function, and consequently a significant impact on
articles, abstracts were reviewed for their relevance and
the quality of life (1).
then were retrieved for full-text analysis. Animal studies and
The mandibular division of the trigeminal nerve is more
single case reports, as well as articles not written in English
susceptible to injury than ophthalmic and maxillary nerves (5).
or articles unavailable for their final full-text assessment
Inferior alveolar nerve (IAN) branch of the trigeminal
were excluded. In order to keep this review as up-to-date
nerve is the most commonly injured branch, followed by
as possible, systematic reviews and meta-analyses published
the lingual nerve (LN) (5,6). These nerves are subjected
within the last 5 years (between years 2015–2020) were
to neurosensorial disturbance (NSD) during third molar
prioritized.
surgery, followed by sagittal split ramus osteotomy (SSRO),
endodontic therapy and dental implant placement (1). Pre-
prosthetic surgery, local anesthetic injections, various types Discussion
of orthognathic surgery, ablative tumor surgery involving
Functional assessment methods
mandibular resections, osteoradionecrosis, osteomyelitis or
maxillofacial trauma are among other potential etiologic IAN and LN injuries occur mainly due to iatrogenic causes
factors (1,7). The risk of mandibular nerve injury during and thus these may, at times, be difficult and troublesome
different procedures ranges between 0.54–39% (5). to explain to patients. A thorough clinical evaluation and
The authors refrain from listing clear surgical indications accurate assessment is crucial, and physicians must have a
or contraindications for nerve repair but rather make formal documentation of the complication both for better
decisions based on both clinical findings and the patients’ outcomes in treatment and also for legal conflicts that
subjective assessment on their clinical status. Accordingly, might arise thereafter. Before any method of assessment,
surgery is indicated for Sunderland Grade IV and V injuries it is important to have an accurate record of the area
either witnessed, or unwitnessed but associated with where a patient experiences the neurosensory deficit with
severe or complete sensory deficit through neurosensory a photograph to be able to use it in future comparisons.
tests (NSTs) at 2 to 6 months or by magnetic resonance The patient’s own subjective assessment is considered
neurography (MRN) any time (2). Yet, if a patient is not the most sensitive indicator since minor disturbances
bothered by their clinical status, ultimately surgery is may be overlooked during testing even with high-tech
contraindicated, as the loss of sensation would likely not get examination modalities. Yet, the ideal method of assessment
worse in the future. is a case under dispute (6). Mechanoreceptive assessment
Data regarding nerve injuries may not always be reliable techniques are static light touch detection, brush directional
since most are based upon personal experience and in discrimination, two-point discrimination (sharp and blunt),
a retrospective nature (1). It is also challenging to draw and nociceptive ones are pin pressure nociception and
proper conclusions from studies on nerve injuries due to the thermal discrimination, both warm and cold (6). Two-
differences in outcome criteria and assessment methods (8). point discrimination may differ in each patient, but the
Still, an accurate knowledge of anatomy should be combined average value is considered around 5 mm. Yet, two-point
with both clinical and radiological data to successfully avoid discrimination is considered unreliable and is poorly
any nerve-related complications (6). This narrative review reproductible owing to its very subjective nature (9). Several
will aim to answer how inferior alveolar and LN injuries other authors rely on diagnostic nerve block as another
occur and are managed, and what the future trends are in method of subjective clinical sensorial assessment when
nerve repairs, through evaluation of the current literature. the patient reports pain as a symptom. Consequently, if

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 3 of 13

pain is relieved after the nerve block, a microneurosurgical resolves the intraneural architecture in multiple orthogonal
intervention may offer a satisfactory prognosis for the planes (16).
patient (6). Currently, there are 2 different magnetic resonance
Light touch sensation, pin-prick sensation and two-point imaging (MRI) methods available to study peripheral
discrimination are the preferred methods of functional nerves: anatomic MRN and diffusion based functional
assessment for LN injuries (10). Von Frey hair is usually MRN, particularly diffusion tensor imaging (DTI).
used to evaluate the light touch sensation in a standardized MRN facilitates the detection of neuropathy by showing
fashion and the answers are scored on a four-point scale, 0 alterations of nerve caliber and abnormal intraneural T2
indicating no response and 3 indicating full response with signal intensity ratio (T2SIR). DTI aids in the functional
no obvious difference from the contralateral side. Pain or evaluation of the intraneural pathophysiology and altered
sharpness is examined through the pin-prick test using a diffusion characteristics correlate with axonal degeneration
sharp probe with 15 g force. Two-point discrimination and demyelination (17).
is performed with the patient’s eyes closed and tongue In several studies, we have demonstrated that MRN
protruded. Both the affected and unaffected sites are tested have moderate to good correlations with the NST levels/
on the tongue first to determine the minimum distance Medical Research Council Scale (MRCS) grading scores
consistently reported as “two points”, which will set the and the surgical findings. The Sunderland Classification
threshold for that specific patient (10). On the other hand, measured before surgery via NST matches with the surgical
according to authors’ clinical expertise, patients usually findings (n=26) in 58% of cases (15/26), overestimating the
cannot discriminate the two points when the distance is surgical findings in 8% of cases (2/26) and underestimating
under 12 mm on the tongue. the surgical findings in 35% of cases (9/26). Overall, MRN
The Tinel’s sign may also serve as a useful tool during provides valuable information about the status of the
evaluation. It is defined as a tingling sensation or pain over IAN and LN injuries and even post-repairs, which affect
the distribution of a nerve after applying pressure over treatment decision and management (18).
the site of injury. Although it is originally developed for The strength of MRN in patient management is the
peripheral nerve testing in the limbs, it is used to evaluate ability to provide non-invasive objective information
injuries involving the LN, since it does not lie protected of the IAN and LN that can distinguish normal from
within a bony canal like the IAN (11). A positive sign is different degrees of neuropathy in the pre-injury, post-
important because it may suggest a neuroma in-continuity injury and post-repair phases. The correlation with
and may aid in the decision for surgery (12). surgical findings is moderate to good and if a randomized
There are also objective sensory tests which are the clinical trial can confirm this relationship with pre-
electrophysiological evaluation of the nerve with an surgical NST, then new strategies in patient management
encephalogram, monitorization of the orthodromic sensory for IAN and LN should lead to quicker detection of non-
nerve action through an electromyogram or the blink reflex, recoverable injuries earlier than the current protocols
which is provoked by an electrical stimulation through and without dependence on patient’s response to clinical
electrodes (13-15). stimulus during NST testing, which should lead to
improved outcomes of repair. Likewise, earlier detection
The role of MRN of recoverable injuries should lead to risk reduction of
Despite exhibiting high positive and negative predictive unnecessary surgical interventions (18).
values for LN injuries (93% and 100% respectively), NSTs
show lower values for IAN injuries, with false-positive and
Factors influencing recovery
false-negative rates of up to 23% and 40%, respectively.
NST results are not reliable in the first month after the Final functional sensory recovery (FSR) is affected
injury because of post-operative changes and the inability by age and pre-operative neurosensory function (8).
of patients and/or physicians to reproduce the sensory Etiology, severity and mechanism of nerve injury,
response. In addition, NST cannot determine the exact site individual neuronal regeneration variability, the degree
of injury or delineate the anatomy for presurgical planning. of neuronal inflammation/infection, cicatricial scar
MRN, an imaging dedicated to the peripheral nerves, formation, experience of the surgeon, and the specific
provides a noninvasive map of neuromuscular anatomy and microneurosurgical techniques used in the repair also do

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For injuries to IAN or LN, 3 to 9 months are allowed for

spontaneous nerve regeneration following the nerve injury,
during which periodic monitoring of the patient is crucial.
A surgical intervention is considered after this period, and if
no FSR is observed (1).
Even the very early studies on nerve repair suggested that
better outcomes are achieved within the first 6 months and
the results of IAN and LN repair are less predictable after
6 months (20-22). More recent studies also suggest that
to achieve a useful FSR after LN or IAN repair, surgical
intervention is better performed within the 9 or 12 months
Figure 1 Traumatic neuroma of the right lingual nerve formed for each nerve, respectively. It is also reported that with
after right mandibular third molar extraction. each month that pass, the odds of improvement decrease
by 5.8% (23).
A recent meta-analysis reveals that an early repair has no
affect the FSR outcomes. significant effects on FSR in eight of the included studies,
The authors emphasize three main principles of but four studies show a positive association between early
microneurosurgery for a successful repair including the repair and recovery. It is noteworthy to mention that the
access, preparation and microsurgery phases. The access definitions of “early” and “late” differ between studies.
phase allows the ability to complete the following phases, Some consider the first 6 months as “early” whereas others
which overall significantly affect the outcome. During this consider three or even the first 2 months after injury as
first phase, exposure should always include normal nerve “early”. Overall, early repair seems to achieve better final
tissue on proximal and distal ends and a recommended FSR compared to delayed or late repair, although the
1 cm of exposure of nerve length is required to allow specific time-period is ambiguous. Once the recovery
preparation and mobilization. An unobstructed view by proves to be below a level of FSR and the expectation is
adequate retraction and retention of adjacent tissues should not towards spontaneous recovery, then timely surgical
be provided. Finally, the surgeon should ensure a surgical intervention may result in an improved outcome (1).
plane for the use of an operating microscope or loupes. Nerve repair within the first 3 months is more likely
The second phase is the preparation phase, aiming to to achieve FSR than a later intervention. Moreover, the
identify normal nerve on the proximal and distal ends. This 6-month time point is also significant to a lesser degree,
phase consists of the release of mesoneurium to explore compared to an even later repair (1).
the epineural tissues for pathologic tissues like a neuroma Early repair, defined as repair completed within 90 days,
(Figure 1) or scar, the identification of normal fascicular results in earlier FSR than repairs done later (24). One
pattern(s) from abnormal (e.g., intrafascicular scar), and if systematic review on LN injuries supports the concept of
abnormal, the resection of nerve ends until normal nerve early repair since it is associated with significantly increased
fascicles are identified through their white, plump and probability of achieving FSR and is found to be the most
protruding look with interfascicular bleeding. Microsurgery significant prognostic factor in FSR outcomes. Although
is the third and final phase, aiming to approximate normal studies differ in their definitions for “early repair”, patients
nerve tissues without any tension (19). Direct neurorrhaphy with LN injuries with indications for surgical intervention
is indicated in case of a nerve gap of 5 mm or less whereas a should receive treatment in an early interval. Borderline
gap larger than 5 mm ideally requires neurorrhaphy with a patients are harder to evaluate during the early phase for
nerve graft (autograft, allograft or conduit). spontaneous recovery since this period is considered as
three to 6 months, coinciding with the early surgical repair
Early vs. late repair period (8).
After Seddon’s publication regarding the factors influencing Contradictory information hinders the proper decision
FSR, the timing from nerve injury to repair has gained making regarding the effect of time of repair on LN repair.
significance and researchers began to investigate the effect Therefore, each surgeon should make a proper judgement
of early intervention on the final outcomes. during the decision-making process. Patients who seek

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 5 of 13

treatment even after a prolonged observation period with supraclavicular nerves (5).
no improvement may still benefit from repair, as long as Autografts provide a suitable environment for nerve
the procedure is truly indicated (8). Authors believe that regeneration. Having no risk of an immunological
especially patients suffering from neuropathic pain usually reaction is the main advantage of an autograft, compared
clinically benefit even from delayed operations. to an allograft which has an uncertain biocompatibility.
Certain algorithms for LN repair are proposed. A Moreover, despite the need for a second surgical site, it is
recent one by Atkins et al. focuses on LN injury following often simple, easy and safe to obtain an autograft (33). The
mandibular third molar removal and indicates surgery in main disadvantages of autografts are donor-site morbidity
cases of observed sectioning of LN intra-operatively, and and limited availability (34). On the other hand, limited
dysesthesia or anesthesia post-operatively after 1 month if supply is not an issue with allografts which also bypass the
recovery is limited or absent (10). need for additional surgical intervention for donor harvest.
Several other studies also report a trend towards better They therefore decrease both the operation time and
outcomes in the early repair although the results fail to potential donor site complications. However cost, potential
reach statistical significance (24-26). One of these studies immunoreaction and risk of disease transmission are major
reveals that an early repair is 2.3 times more likely to result setbacks for allografts (5,35). Histologically, acellular grafts
in FSR at 1 year but the outcome between early and late show similar axonal regeneration patterns as autografts (5).
repair groups at final follow up show no difference (24). Yet There are also non-absorbable and absorbable non-
there are several other studies failing to identify the time to biological conduits. Non-absorbable ones remain within
repair as a significant factor influencing the neurosensory the tissues and may initiate a foreign body reaction or
recovery (1,26-28). cause irritation whereas the absorbable ones function as
temporary scaffolds (5). Conduits from autogenous vein
Direct vs. indirect repair grafts show successful results for gaps of less than 5mm in
Nerve grafts provide positive results in IAN and LN repairs LN reconstruction and for gaps ranging between 5–14 mm
(26,29). Some studies report better long-term results in IAN repair (36).
observed with nerve grafts, both objectively and subjectively, The current knowledge fails to show any difference
compared to direct nerve repair due to decreased tension at between IAN or LN for primary reconstruction (7).
the repair site (27). Nerve regeneration can be negatively There is a risk of graft collapse with the movement of the
impacted by tension, which constricts the cross-sectional tongue in LN, which is not a concern for IAN since it is
area of the fascicles of the nerve. This constriction increases located within a bony canal (36). On the other hand, since
the internal pressure thus compromising the intra fascicular the LN is not constricted within a bony canal, it can be
nutritive blood flow (2,4). Preclinical studies have shown further mobilized by dissection. Within studies where any
ischemia with as little as 5% elongation and impaired difference in FSR is observed between IAN and LN repair,
axonal regeneration with 7.4% nerve elongation. For the this may be credited to the inability to adequately mobilize
trigeminal nerve this is approximately 5 mm. the IAN and ensure a tension free repair, and not because
Excessive tension may be determined intra-operatively if there is an inherent difference in nerve recovery (7).
both ends of the nerve fails to hold using a 9-0 nylon suture. In a systematic review to assess the outcomes of direct
Ideally, four to six sutures are placed depending on the LN repair, six studies were fit to be analyzed. British
nerve size. Placing an adequate number of sutures is advised Medical Research Council (BMRC) criteria was accepted
since too many sutures may initiate more inflammatory for all six studies, which helped to standardize the level
reaction. of recovery after the surgical intervention. Accordingly,
Autologous nerve grafts from sural nerve or the greater FSR was determined as S3 or higher on BMRC scale.
auricular nerve are commonly applied for IAN or LN Consequently, the review failed to reveal a significant
repair, since they provide a good match for the number relationship between FSR and conduit use (8). Authors
of fascicles (5). The supraclavicular, long thoracic, and believe a greater number of randomized clinical trials and
cervical plexus nerves are also suggested (5,30-32). On prospective studies are necessary to draw definitive lines
the other hand, transverse cervical and lesser occipital regarding the positive effects of conduit use on FSR of IAN
nerves are considered less reliable than great auricular and and LN repairs.

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therapy may also be considered (6).

If a NS D exists post- oper atively after a w eek ,
examinations should be continued weekly for 3 weeks
followed by every 2 to 3 weeks for 12 weeks (6).
One theory is that successful surgical intervention is
most predictable when performed before total Wallerian
degeneration of the distal portion of the nerve has occurred,
which is approximately 3 months or, for several other
authors, may take up to 4 to 6 months, due to the slow
degeneration process of the nerve (6,40).
The surgical management of peripheral nerve injuries
range from external neurolysis to direct microsuturing,
gluing, grafting, tubulization, and laser welding (41). If
tension-free repair is achievable, direct neurorrhaphy
(Figure 2) should be indicated. Even though its limited
Figure 2 Direct neurorrhaphy of a left lingual nerve without applicability, additional dissection and mobilization of a
tension using four 8.0 prolene sutures. nerve may be beneficial to minimize or eliminate a nerve
gap (7). Juodzbalys et al. suggest that the best results are
obtained with a direct anastomosis of the two ends of the
Management nerve to be repaired (6). However, this may be impractical
especially in mandibular resection operations which often
It is important to understand the overwhelming aspect result in IAN discontinuity. In such cases, nerve-sparing
of a nerve injury on the patient’s quality of life and techniques as well as immediate reconstruction using
accordingly provide a psychological treatment as well, autogenous nerve grafts or nerve allografts have been
through immediate information, explanation, support and reported (42,43).
reassurance of realistic expectations from the treatment Besides an end-to-end repair, other techniques including
(6,37). decompression through external and internal neurolysis,
There is still need for a clear consensus on how IAN or excision and direct or indirect anastomosis using an
LN should be evaluated post-operatively (9). Neurosensorial autogenous sural, greater auricular or medial antebrachial
assessments are performed through fine touch, pin-prick nerve graft, saphenous vein graft, or alloplastic, collagen
pain, two-point discrimination, thermal testing, taste testing or polyglycolic acid tubes show variable results (6). When
and fungiform papillae examination in LN injury cases (1). direct neurorrhaphy is impracticable, grafts or conduits are
Initially, acute nerve injury treatment starts with used to bridge the nerve gap (7). Autologous nerve graft
medical therapy. Pharmacologically, an acute nerve (Figure 3) is considered the gold standard for the repair of
injury may benefit from corticosteroids or non-steroid a long nerve gap, even though it constitutes disadvantages
anti-inflammatory drugs (NSAIDs). High doses of such as the need for a second surgical site, scarring, donor
adrenocorticosteroids within the first week of injury is site morbidity, neuroma formation, loss of sensitivity at the
considered useful in minimizing neuropathy as well as donor site and limited availability (7,41).
inhibiting neuroma formation (6,38). Topical application Alternatively, tubulization (Figure 4) provides a favorable
of dexamethasone (in intravenous form) helps reduce microenvironment through a conduit inside of which
neural inflammation and enhance recovery, when a known cellular components and growth factors can be added to
or observed trauma is witnessed intra-operatively (39). enhance nerve regeneration (41). These conduits may
However, it is crucial to either indicate a microneurosurgical either be synthetic (non-resorbable, silicone) or resorbable
intervention or to refer patients to a microneurosurgeon (type I collagen, polyglycolic acid, or porcine intestinal
when IAN transection is observed intra-operatively (6). submucosa) (7). Their use for nerve reconstruction of
Antidepressants, anticonvulsants, antisympathetic drugs or gaps larger than 6 mm is not advisable. Alternatively,
physiological therapies such as transcutaneous electric nerve conduits may aid in promoting nerve regeneration after
stimulation, acupuncture, cryotherapy and low-level laser direct neurorrhaphy of nerve gaps less than 6 mm (7,44).

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 7 of 13

A B

Figure 3 Autologous nerve graft: (A) arrow shows exposed right sural nerve during dissection; (B) sural nerve graft sample harvested and
prepared to be used for an inferior alveolar nerve injury repair.

Despite their limited efficacy in nerve gaps, they are evaluate through serial NSTs or consider getting an MRN.
advocated as adjuncts, to either primary repairs or allograft Although the literature suggests several ways to manage
reconstructions, as nerve wraps or connector-assisted an already osseointegrated implant either through its
repairs around the coaptation site (7). removal or by apicoectomy of the implant, these are not
Processed nerve allografts (PNAs) help avoid donor-site very practical methods to use (6). The authors suggest to
complications due to autograft harvesting. Human PNAs leave the implant and instead repair the nerve apical to the
(Figure 4) are extracellular matrix scaffolds created from implant using standard techniques.
donated human peripheral nerve tissues that has been pre- Similarly, processed and acellular nerve allografts have
degenerated, decellularized, and sterilized (7). promising but variable results. We have previously reported
Some studies report that a tension-free coaptation that FSR is achieved in 90% of patients after a mandibular
with a conduit or connector is associated with less sensory resection surgery, involving the reconstruction of IAN
disturbance than direct neurorrhaphy for both IAN and with a PNA (42). On the other hand, the main setback for
LN reconstructions, providing 95% and 89% FSR rates, an acellular nerve graft (ANG) so far has been its inability
respectively (7,45). to effectively reconstruct nerve gaps larger than 20 mm
If IAN injury is encountered after implant surgery, (29,42). Yet, PNAs are not recommended for nerve gaps
removal of the implant may be considered within the longer than 3 cm in non-trigeminal sites and the immediate
36 hours, post-operatively, when a contact with or pressure reconstruction of IAN with PNA in long gaps (45–70 mm)
is suspected onto the mandibular canal (46). Nonetheless, have resulted in functional sensory impairment in small-
removal of the implant may not always resolve any injuries diameter (2–3 mm) nerves (42).
especially when the injury may be related to other sources Either neuroma-in-continuity or proximal terminal
than impingement such as inadvertent drilling through the neuroma may be encountered as a serious complication
IAN. The surgeon should carefully monitor the patient, following LN injury which may be managed with a variety

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and gingiva until the second premolar as well as the skin

of the mental area. Daily tasks including speaking, eating,
drinking, kissing, applying make-up or shaving may be
affected (6).
Complete or partial transection, extension, compression,
crushing or ischemia of the IAN may have a clinical
presentation of nerve damage (9). Common risk factors
for IAN injury are older age and female gender and
although injury due to local anesthesia is very rare, it is
also a major concern for IAN injury. Almost up to 9% of
patients experience an “electric shock” during an IAN block
application of which 57% suffer further from prolonged
neuropathy (6). Luckily, these commonly resolve on
their own within 8 weeks without a need for a surgical
Figure 4 Sample of a connector-assisted-repair: a processed nerve intervention, but may benefit from medical treatments.
allograft (AVANCE®, AxoGen Inc, Alchuala, Florida, USA) is As far as implant surgery is concerned, several authors
selected based on length of the defect and diameter of the proximal advocate the use of local infiltration instead of an IAN
left lingual nerve stump. The allograft is then sutured on the back block, even though it is not generally used due to the nerve
table to a porcine nerve connector (AxoGuard Connector, 4 mm endings within the bone which may cause discomfort during
× 10 mm, Axogen Inc., Alchuala, Florida, USA) using 8.0 nylon surgery (6). The authors strongly advise not to rely on local
sutures at the 12 o’clock positions at each end. The graft is then infiltrative anesthesia in the prevention of IAN injury as
brought into the surgical field and the distal and proximal stumps they have experienced numerous cases being referred with
are secured to the nerve connector in a similar fashion with 8.0 IAN injuries during dental implant operations performed
nylon sutures. using only infiltrative local anesthesia instead of regional
mandibular blocks. Chemical properties of a local anesthetic
agent may also be considered as a possible etiological factor
of different techniques including end-to-end anastomosis, for IAN injury. Several studies advocate that prilocaine (4%)
or indirect repair using autograft or allograft (10). Several and articaine (4%) are more prone to such injury, per use,
studies favor end-to-end anastomosis since they result in the than lidocaine (6,48). This is attributed to the degree of
best outcome, advocating that intraneural scar formation is inflammatory reaction to the local anesthetic since lidocaine
a major setback against neural recovery and a single repair is reportedly less irritant than articaine (49). Overall,
site may result in better outcomes (10,47). On the other demyelination, axonal degeneration and inflammation of the
hand, grafting may be a better choice when the nerve gap is surrounding nerve fibers within the fascicles are listed as the
large and possibly increase the tension on the repair (10,27). main factors resulting in a chemical injury (50). Ideally, it
is recommended to contact each patient after the proposed
effect of local anesthesia has worn of, approximately 6 hours
Special considerations on the IAN
after the surgery to make sure that the patient does not have
IAN injury, similar to LN injury, may commonly arise due an ongoing anesthesia or a neuropathic condition (46).
to iatrogenic causes such as third molar extractions, dental Specific to implant surgery, injuries due to implant drill
implant placement, endodontic treatments, orthognathic or the dental implant, and an incorrect surgical technique
surgery, dentoalveolar pathology, and even because of are listed as the main etiological factors. Additionally, an
anesthetic needles or the toxic effects of the anesthetic IAN injury may occur either intra-operatively (mechanical,
agents themselves. IAN injury is one of the serious thermal or chemical injuries), or post-operatively (indirect
complications of implant surgery with an incidence of up to injury due to thermal stimuli, infection or hematoma
40% (6). resulting in scarring and ischemia). Mechanical etiological
Clinically, IAN injury may result in an altered sensation, factors, the implant drill or the implant itself, may either
such as anesthesia, paresthesia or dysesthesia, with or have a direct or indirect effect on IAN, consequently
without pain in the ipsilateral lower lip, mucous membrane causing ischemia or nerve degeneration. The implant or the

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 9 of 13

drill or may partially/fully intrude the mandibular canal, or respectively (7). The risk of LN injury is greater during
cause a thermal stimulus evoking bony necrosis (6). mandibular third molar extractions where distobuccal bone
Some authors propose that even when the roof the removal is performed (55). Improper instrument placement
mandibular canal is cracked, hemorrhage and debris during lingual retraction and excessive retraction also
deposits may compress and result in an ischemia of the IAN increase the incidence of LN injury (56).
and the injury may persist even when the implant is backed- Clinically, LN injury may cause loss of sensation to the
up or replaced with a shorter one (46). Post-operative ipsilateral anterior tongue and lingual mucoperiosteum (55).
infection or peri-implant lesions may also result in an IAN Other symptoms may include neuropathic pain (most
injury, as well as iatrogenic injuries due to incorrect surgical likely due to neuroma formation), reduced or altered
technique (6). taste, impaired speech or unintentional tongue biting (10).
IAN damage may also occur due to SSRO (9). Nerve Patients experiencing such symptoms should be informed
damage may result from compression or movement by that without an intervention, those with no signs of
bone fragments, direct mechanical stimulation of the nerve significant resolution by 3 months are unlikely to recover
or an indirect damage (51). The incidence of IAN damage spontaneously (10).
after SSRO ranges between 0–85% in the literature (9). Surgical intervention for LN repair 6 months after the
Persistent IAN hypoesthesia is the most commonly reported injury may have a higher risk of neuropathic pain or may
complication after SSRO (52). offer no difference (57). Yet, the majority of patients with
Nerve damage may occur at different stages during initial symptoms of neuropathic pain are relieved from this
SSRO, such as during the dissection of soft tissues medial pain after surgical intervention. Even though significant
to the mandibular ramus, mandibular sawing, splitting, improvements are observed in terms of recovery, Atkins
advancement or fragment fixation. Interestingly, split type is et al. suggest that no patient experiences a complete
not found to affect the rate of post-operative neurosensory recovery. Still, surgery seems to be the most worthwhile
disturbance (9). Age, type of fixation, surgical technique option for patients with pain (10).
and experience, magnitude of mandibular movement A surgical intervention for LN injury is considered
and the position of the IAN are the main risk factors of when there is significant anesthesia or neuropathic pain
neurosensory disturbance after SSRO (52). in the form of dysesthesia or hyperalgesia. A significantly
IAN lateralization and repositioning may also result less incidence of tongue-biting is observed in patients
in neurosensory complications in 95.5% and 58.9% of after surgical intervention which may be attributed to an
patients, 3.4% and 22.1% of which experience a permanent improved pin-prick detection (10). Other surgical outcomes
injury, respectively (53). may be listed as significantly reduced threshold during two-
An incorrect surgical technique may result in an IAN point discrimination and an improved ability to detect light
injury due to the wrong use of scalpel or sutures, and touch (10).
improper use of reflectors or false soft tissue reflection. There are contradictory reports regarding how taste is
Although these factors usually result in direct nerve injury, affected after the surgical repair of the LN. Several authors
IAN injury may also be encountered because of soft tissue report a lack of improvement in taste whereas others show
edema post-operatively after an improper operation variable degrees of improvement in gustatory function (10).
technique (6). Nakanishi et al. suggests that poorer outcomes in taste may
be associated with delayed surgery (28).
Although there are special instruments designed
Special considerations on the LN
specifically for lingual flap retraction, such as the Hovell,
Running subperiosteally at the lingual aspect of the Walter, and Rowe elevators, many surgical instruments
posterior mandible, the LN anatomically has a close relation are used beyond their initial purpose (58). The Howarth
with mandibular third molars, extractions of which are one periosteal elevator, which is originally designed as a nasal
of the most common surgical procedures (54,55). Iatrogenic mucoperiosteal elevator, is in fact a good example for
LN injuries occur most frequently due to mandibular such repurposed instruments, since it is most commonly
third molar extractions. Patients experience temporary or used for lingual retraction. Similarly, the Freer, Molt, and
permanent paresthesia in 4.4% and 1% of cases, which Obwegeser narrow periosteal elevators are repurposed as
annually translate into 154,000 and 35,000 patients, lingual retractors (55). One study comparing the use of no

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:27 | https://dx.doi.org/10.21037/fomm-21-8
Page 10 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

lingual retractors, repurposed and purpose-built lingual sensory re-training immediately post-operatively using a
retractors reveal that the risk of LN injury is increased toothbrush to stimulate sensory nerves on the tongue or a
when repurposed retractors are used than with no lingual cotton tip on the lip and chin in front of a mirror (59).
retractor. Using a purpose-built instrument provides the Serial formal sensory exams should begin at the earliest
lowest risk of injury (55). post-operative 1 month (preferably on the third month)
When the extractions are done by fracturing the lingual and continue monthly assessing for improvement up
plate of the alveolar socket, also known as the lingual split, to a year. If patients fail to improve at 3 to 6 months
there is a higher incidence of temporary injury but a lower post-repair, a repeat MRN can be completed to assess
incidence of permanent damage than lingual retraction formation of secondary neuromas which may require a
alone (56). Therefore, Rapaport et at. suggests that second surgery.
although permanent nerve injuries are uncommon, using Innovative research on nerve repair focuses on further
purpose-built lingual flap retractors may help avoid the optimizing clinical outcomes. One of the future trends for
overwhelming consequences for the patients (55). nerve repair will be the third-generation conduits, which
are currently under development. These will incorporate
stem cells, Schwann cells or extracellular matrix proteins,
Conclusions
and allow controlled delivery of neurotrophic factors for
Damage to the inferior alveolar or LNs may have guided regrowth (7,60). Similarly, allograft modifications
devastating consequences both for the patients and the including nerve growth promoting factors or the application
physicians. It is important to consider the etiological factors of electric or magnetic stimulation are among future
and make an appropriate pre-operative assessment to avoid considerations (7).
nerve injury. Even if it happens, a timely diagnosis and a Finally, even though there are promising clinical studies
proper management are key to avoid further or permanent on the use of preparation rich in growth factor (PRGF),
damage. platelet-rich fibrin (PRF) or platelet-rich plasma (PRP) as
Although the literature supports the tendency towards adjunctive methods for nerve repair, the clinical data on
the concept of management as “earlier is better”, delayed their use is limited and many reports are based on animal
repairs also show acceptable neurosensory recovery studies (41,52,53,61). New prospective studies are necessary
outcomes (1). Within the first 3 months after injury, nerve to evaluate the possibly positive effects of these autologous
repair for IAN and LN has a better chance of achieving blood concentrates as well as hyperbaric oxygen therapy as
FSR than a later intervention. Although it is significant to adjunctive methods for nerve repair.
a lesser degree, the 6-month time point also differs than an
even later repair (1).
Acknowledgments
For LN repairs, conduits seem to have a positive
effect on neurosensory recovery and early repair is highly Funding: None.
correlated with increased FSR compared to late repairs (8).
Currently, autografts and allografts, as well as primary
Footnote
tension-free repairs are reportedly found superior to
conduits in achieving FSR. Conduits may prove to be Provenance and Peer Review: This article was commissioned
beneficial in nerve gaps of 6 mm or less, however this by the Guest Editor (Sung-Kiang Chuang) for the
information is yet to be further evaluated through newer series “Clinical Outcomes and Innovations in Oral and
studies with larger sample sizes. Within autografts, Maxillofacial Surgery” published in Frontiers of Oral and
allografts and primary repairs, no statistical differences are Maxillofacial Medicine. The article has undergone external
observed since they have all achieved FSR at comparable peer review.
rates (7).
Patients should be advised to avoid self-inflicted trauma Peer Review File: Available at https://fomm.amegroups.com/
in the immediate post-operative period when hypoesthesia article/view/10.21037/fomm-21-8/prf
may initially be increased. Jaw opening physiotherapy is
advised after LN repair due to stripping of the medial Conflicts of Interest: All authors have completed the ICMJE
pterygoid during surgical exposure. Patients can begin uniform disclosure form (available at https://fomm.

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 11 of 13

amegroups.com/article/view/10.21037/fomm-21-8/coif). Lingual Nerve Repair After an Injury: A Systematic

The series “Clinical Outcomes and Innovations in Oral and Review. J Oral Maxillofac Surg 2021;79:697-703.
Maxillofacial Surgery” was commissioned by the editorial 9. Martinez-de la Cruz G, Yamauchi K, Saito S, et al. The
office without any funding or sponsorship. JRZ is a paid relationship between neurosensory disturbance of the
consultant for AxoGen, Inc. and his contributions to this inferior alveolar nerve and the lingual split pattern after
publication were not supported by or reviewed by AxoGen, sagittal split osteotomy. Oral Surg Oral Med Oral Pathol
Inc. The authors have no other conflicts of interest to Oral Radiol 2020;130:373-8.
declare. 10. Atkins S, Kyriakidou E. Clinical outcomes of lingual nerve
repair. Br J Oral Maxillofac Surg 2021;59:39-45.
Ethical Statement: The authors are accountable for all 11. Nerve Evaluation Protocol 2014. California Association of
aspects of the work in ensuring that questions related Oral and Maxillofacial Surgeons, 2014.
to the accuracy or integrity of any part of the work are 12. Donoff RB, Fagin AP. Lingual and inferior alveolar
appropriately investigated and resolved. nerve injuries after third molar removal. Alpha Omegan
2013;106:91-5.
Open Access Statement: This is an Open Access article 13. Nakagawa K, Ueki K, Takatsuka S, et al. Somatosensory-
distributed in accordance with the Creative Commons evoked potential to evaluate the trigeminal nerve after
Attribution-NonCommercial-NoDerivs 4.0 International sagittal split osteotomy. Oral Surg Oral Med Oral Pathol
License (CC BY-NC-ND 4.0), which permits the non- Oral Radiol Endod 2001;91:146-52.
commercial replication and distribution of the article with 14. Jääskeläinen SK, Teerijoki-Oksa T, Forssell K, et al.
the strict proviso that no changes or edits are made and the Intraoperative monitoring of the inferior alveolar nerve
original work is properly cited (including links to both the during mandibular sagittal-split osteotomy. Muscle Nerve
formal publication through the relevant DOI and the license). 2000;23:368-75.
See: https://creativecommons.org/licenses/by-nc-nd/4.0/. 15. Jääskeläinen SK. Blink reflex with stimulation of the
mental nerve. Methodology, reference values, and some
clinical vignettes. Acta Neurol Scand 1995;91:477-82.
References
16. Dessouky R, Xi Y, Zuniga J, et al. Role of MR
1. Suhaym O, Miloro M. Does early repair of trigeminal Neurography for the Diagnosis of Peripheral Trigeminal
nerve injuries influence neurosensory recovery? A Nerve Injuries in Patients with Prior Molar Tooth
systematic review and meta-analysis. Int J Oral Maxillofac Extraction. AJNR Am J Neuroradiol 2018;39:162-9.
Surg 2021;50:820-9. 17. Thawait SK, Chaudhry V, Thawait GK, et al. High-
2. SUNDERLAND S. A classification of peripheral nerve resolution MR neurography of diffuse peripheral nerve
injuries producing loss of function. Brain 1951;74:491-516. lesions. AJNR Am J Neuroradiol 2011;32:1365-72.
3. Althagafi A, Nadi M. Acute Nerve Injury. In: StatPearls. 18. Zuniga JR, Mistry C, Tikhonov I, et al. Magnetic
Treasure Island (FL): StatPearls Publishing; 2021. Resonance Neurography of Traumatic and Nontraumatic
4. Miloro M. Microneurosurgery. In: Miloro M, Ghali Peripheral Trigeminal Neuropathies. J Oral Maxillofac
GE, Larsen P, et al. Peterson's Principles Of Oral & Surg 2018;76:725-36.
Maxillofacial Surgery. 3rd edition. Connecticut, USA: 19. Tay AB, Zuniga J. Nerve Repair. In: Haggerty CJ,
PMPH-USA, 2011:919-41. Laughlin RM, editors. Atlas of operative oral and
5. Liu X, Daugherty R, Konofaos P. Sensory Restoration of maxillofacial surgery. John Wiley & Sons, 2015:522-34.
the Facial Region. Ann Plast Surg 2019;82:700-7. 20. Mozsary PG, Middleton RA. Microsurgical
6. Juodzbalys G, Wang HL, Sabalys G. Injury of the Inferior reconstruction of the lingual nerve. J Oral Maxillofac
Alveolar Nerve during Implant Placement: a Literature Surg 1984;42:415-20.
Review. J Oral Maxillofac Res 2011;2:e1. 21. Mozsary PG, Syers CS. Microsurgical correction of the
7. Ducic I, Yoon J. Reconstructive Options for Inferior injured inferior alveolar nerve. J Oral Maxillofac Surg
Alveolar and Lingual Nerve Injuries After Dental and 1985;43:353-8.
Oral Surgery: An Evidence-Based Review. Ann Plast Surg 22. Donoff RB. Surgical management of inferior alveolar
2019;82:653-60. nerve injuries (Part I): The case for early repair. J Oral
8. Kogan M, Lee KC, Chuang SK, et al. Outcomes of Direct Maxillofac Surg 1995;53:1327-9.

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:27 | https://dx.doi.org/10.21037/fomm-21-8
Page 12 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

23. Bagheri SC, Meyer RA, Khan HA, et al. Retrospective implants in the anterior mandible: an initial questionnaire
review of microsurgical repair of 222 lingual nerve injuries. approach followed by a psychophysical assessment. Clin
J Oral Maxillofac Surg 2010;68:715-23. Oral Investig 2006;10:269-77.
24. Susarla SM, Kaban LB, Donoff RB, et al. Does early 38. Han SR, Yeo SP, Lee MK, et al. Early dexamethasone
repair of lingual nerve injuries improve functional sensory relieves trigeminal neuropathic pain. J Dent Res
recovery? J Oral Maxillofac Surg 2007;65:1070-6. 2010;89:915-20.
25. Strauss ER, Ziccardi VB, Janal MN. Outcome assessment 39. Misch C. Root Form Surgery in the Edentulous Anterior
of inferior alveolar nerve microsurgery: a retrospective and Posterior Mandible: Implant Insertion. In: Misch C.
review. J Oral Maxillofac Surg 2006;64:1767-70. Contemporary Implant Dentistry. 3rd edition. St. Louis,
26. Zuniga JR. Sensory outcomes after reconstruction of MO: Elsevier Health Sciences, 2008:221-6.
lingual and inferior alveolar nerve discontinuities using 40. Kraut RA, Chahal O. Management of patients with
processed nerve allograft--a case series. J Oral Maxillofac trigeminal nerve injuries after mandibular implant
Surg 2015;73:734-44. placement. J Am Dent Assoc 2002;133:1351-4.
27. Miloro M, Ruckman P 3rd, Kolokythas A. Lingual Nerve 41. Bastami F, Vares P, Khojasteh A. Healing Effects of
Repair: To Graft or Not to Graft? J Oral Maxillofac Surg Platelet-Rich Plasma on Peripheral Nerve Injuries. J
2015;73:1844-50. Craniofac Surg 2017;28:e49-57.
28. Nakanishi T, Yamamoto Y, Tanioka K, et al. Effect 42. Zuniga JR, Williams F, Petrisor D. A Case-and-Control,
of duration from lingual nerve injury to undergoing Multisite, Positive Controlled, Prospective Study of the
microneurosurgery on improving sensory and taste Safety and Effectiveness of Immediate Inferior Alveolar
functions: retrospective study. Maxillofac Plast Reconstr Nerve Processed Nerve Allograft Reconstruction With
Surg 2019;41:61. Ablation of the Mandible for Benign Pathology. J Oral
29. Yampolsky A, Ziccardi V, Chuang SK. Efficacy of Acellular Maxillofac Surg 2017;75:2669-81.
Nerve Allografts in Trigeminal Nerve Reconstruction. J 43. Salomon D, Miloro M, Kolokythas A. Outcomes of
Oral Maxillofac Surg 2017;75:2230-4. Immediate Allograft Reconstruction of Long-Span Defects
30. Mucci SJ, Dellon AL. Restoration of lower-lip sensation: of the Inferior Alveolar Nerve. J Oral Maxillofac Surg
neurotization of the mental nerve with the supraclavicular 2016;74:2507-14.
nerve. J Reconstr Microsurg 1997;13:151-5. 44. Lohmeyer JA, Kern Y, Schmauss D, et al. Prospective
31. Audolfsson T, Rodríguez-Lorenzo A, Wong C, et al. clinical study on digital nerve repair with collagen nerve
Nerve transfers for facial transplantation: a cadaveric study conduits and review of literature. J Reconstr Microsurg
for motor and sensory restoration. Plast Reconstr Surg 2014;30:227-34.
2013;131:1231-40. 45. Ducic I, Safa B, DeVinney E. Refinements of nerve
32. Schultes G, Gaggl A, Kärcher H. Transplantation of the repair with connector-assisted coaptation. Microsurgery
vascular pedicled thoracicus longus nerve for recovering 2017;37:256-63.
sensory capacities in the mentalis nerve supply region. 46. Khawaja N, Renton T. Case studies on implant removal
Mund Kiefer Gesichtschir 1999;3:1-5. influencing the resolution of inferior alveolar nerve injury.
33. Gao Y, Wang YL, Kong D, et al. Nerve autografts and Br Dent J 2009;206:365-70.
tissue-engineered materials for the repair of peripheral 47. Zuniga JR, Yates DM. Factors Determining Outcome
nerve injuries: a 5-year bibliometric analysis. Neural Regen After Trigeminal Nerve Surgery for Neuropathic Pain. J
Res 2015;10:1003-8. Oral Maxillofac Surg 2016;74:1323-9.
34. Trehan SK, Model Z, Lee SK. Nerve Repair and Nerve 48. Hillerup S, Jensen R. Nerve injury caused by
Grafting. Hand Clin 2016;32:119-25. mandibular block analgesia. Int J Oral Maxillofac Surg
35. Siemionow M, Sonmez E. Nerve allograft transplantation: 2006;35:437-43.
a review. J Reconstr Microsurg 2007;23:511-20. 49. Ribeiro PD Jr, Sanches MG, Okamoto T. Comparative
36. Pogrel MA, Maghen A. The use of autogenous vein grafts analysis of tissue reactions to anesthetic solutions:
for inferior alveolar and lingual nerve reconstruction. J histological analysis in subcutaneous tissue of rats. Anesth
Oral Maxillofac Surg 2001;59:985-8; discussion 988-93. Prog 2003;50:169-80.
37. Abarca M, van Steenberghe D, Malevez C, et al. 50. Malamed S. What's new in local anaesthesia? SAAD Dig
Neurosensory disturbances after immediate loading of 2009;25:4-14.

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:27 | https://dx.doi.org/10.21037/fomm-21-8
Frontiers of Oral and Maxillofacial Medicine, 2022 Page 13 of 13

51. Yamauchi K, Takahashi T, Kaneuji T, et al. Risk factors molar surgery: a systematic review of the literature.
for neurosensory disturbance after bilateral sagittal split Oral Surg Oral Med Oral Pathol Oral Radiol Endod
osteotomy based on position of mandibular canal and 2001;91:395-401.
morphology of mandibular angle. J Oral Maxillofac Surg 57. Renton T, Yilmaz Z, Gaballah K. Evaluation of trigeminal
2012;70:401-6. nerve injuries in relation to third molar surgery in
52. Tabrizi R, Pourdanesh F, Jafari S, et al. Can platelet-rich a prospective patient cohort. Recommendations for
fibrin accelerate neurosensory recovery following sagittal prevention. Int J Oral Maxillofac Surg 2012;41:1509-18.
split osteotomy? A double-blind, split-mouth, randomized 58. Pogrel MA, Goldman KE. Lingual flap retraction for third
clinical trial. Int J Oral Maxillofac Surg 2018;47:1011-4. molar removal. J Oral Maxillofac Surg 2004;62:1125-30.
53. Anitua E, Alkhraisat MH. The adjuvant use of plasma 59. Phillips C, Blakey G 3rd, Essick GK. Sensory retraining:
rich in growth factors in the inferior alveolar nerve a cognitive behavioral therapy for altered sensation. Atlas
repositioning technique. Heliyon 2019;5:e02965. Oral Maxillofac Surg Clin North Am 2011;19:109-18.
54. Baqain ZH, Abukaraky A, Hassoneh Y, et al. Lingual 60. Gaudin R, Knipfer C, Henningsen A, et al. Approaches
nerve morbidity and mandibular third molar surgery: a to Peripheral Nerve Repair: Generations of Biomaterial
prospective study. Med Princ Pract 2010;19:28-32. Conduits Yielding to Replacing Autologous Nerve
55. Rapaport BHJ, Brown JS. Systematic review of lingual Grafts in Craniomaxillofacial Surgery. Biomed Res Int
nerve retraction during surgical mandibular third molar 2016;2016:3856262.
extractions. Br J Oral Maxillofac Surg 2020;58:748-52. 61. Sánchez M, Garate A, Delgado D, et al. Platelet-rich
56. Pichler JW, Beirne OR. Lingual flap retraction and plasma, an adjuvant biological therapy to assist peripheral
prevention of lingual nerve damage associated with third nerve repair. Neural Regen Res 2017;12:47-52.

doi: 10.21037/fomm-21-8
Cite this article as: Selvi F, Yildirimyan N, Zuniga JR. Inferior
alveolar and lingual nerve injuries: an overview of diagnosis and
management. Front Oral Maxillofac Med 2022;4:27.

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:27 | https://dx.doi.org/10.21037/fomm-21-8