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Surgery to the mandibular third molar is common, and injuries to the inferior alveolar nerve and the lingual nerve are well-recognized complications of this procedure. The aim of these technical notes is to describe operative measures for reducing neurological complications during mandi - bular third molar surgery. The following procedure should be used to prevent damage to the inferior alveolar nerve: a welldesigned mucoperiosteal flap, to obtain appropriate access to the surgical area; a conservative ostectomy on the distal and distal-lingual side; tooth sectioning, to facilitate its removal by decreasing the retention zones; tooth dislocation in the path of withdrawal imposed by the curvature of the root apex; and careful socket debridement, when the roots of the extracted tooth are in intimate contact with the mandibular canal. To prevent injury to the lingual nerve, it is important (I) to assess the integrity of the mandibular inner cortex and exclude the presence of fenestration, which could cause the dislocation of the Annali di Stomatologia 2017;VIII (2):45-52 45 tooth or its fragment into the sublingual or submandibular space; (II) to avoid inappropriate or excessive dislocation proceedings, in order to prevent lingual cortex fracture; (III) to perform horizontal mesial-distal crown sectioning of the lingually inclined tooth; (IV) to protect the lingual flap with a retractor showing the cortical ridge; and (V) to pass the suture not too apically and from the inner side in a buccal-lingual direction in the retromolar area.
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Annali di stomatologia
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Prevention of neurological injuries during mandibular third molar surgery: technical notes
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Prevention of neurological injuries during mandibular third molar surgery: technical notes
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                                                                                                 Original article


    Prevention of neurological injuries during
    mandibular third molar surgery: technical notes




                                                                                              li
                                                                                            na
    Gerardo La Monaca1 DDS, PhD                            tooth or its fragment into the sublingual or sub-
    Iole Vozza2 DDS, PhD                                   mandibular space; (II) to avoid inappropriate or
    Rita Giardino2 DDS, PhD                                excessive dislocation proceedings, in order to




                                                                                          io
    Susanna Annibali2 MD, DDS                              prevent lingual cortex fracture; (III) to perform
    Nicola Pranno2 DDS, PhD                                horizontal mesial-distal crown sectioning of the
    Maria Paola Cristalli3 DDS, PhD,                       lingually inclined tooth; (IV) to protect the lingual




                                                                     az
                                                           flap with a retractor showing the cortical ridge;
                                                           and (V) to pass the suture not too apically and

      Department of Sense Organs, “Sapienza” University
                                                           from the inner side in a buccal-lingual direction in
    1

    of Rome, Rome, Italy
                                                           the retromolar area.

    2 Department of Oral and Maxillo-Facial Sciences,




                                                                   rn
    “Sapienza” University of Rome, Rome, Italy
                                                           Key words: inferior alveolar nerve injury, lingual

    3 Department of Biotechnologies and Medical Surgical
                                                           nerve injury, intraoperative complications, third

    Sciences, “Sapienza” University of Rome, Rome,
                                                           molar, oral surgery.




                                                    te
    Italy
                                                           Introduction

                                                           Surgery to the mandibular third molar is common, but
                                                  In
                                                           injuries to the inferior alveolar nerve (IAN) and the lin-
    Gerardo La Monaca                                      gual nerve (LN) remain well-recognized complica-
    Corresponding author:

    Department of Sense Organs,                            tions. The reported incidence of nerve damage during
    “Sapienza” University of Rome                          this procedure has been reported to range from 0.26
                                ni

    Via Caserta 6                                          to 8.4% for IAN and from 0.1 to 22% for LN (1). The
    00161 Rome, Italy                                      wide variability of these values makes it impossible to
    E-mail: gerardo.lamonaca@uniroma1.it                   provide a reliable estimate owing to differences in
                              io


                                                           surgical technique, examined samples, follow-up and
                                                           evaluation criteria used in the studies that have been
                                                           reported in the literature.
                                                           The following risk factors for IAN injuries in third mo-
                            iz



                                                           lar surgery have been reported in the literature: high-
    Summary

                                                           er patient’s age, pre-existing disease, deep impaction
                                                           and close anatomic relationship between the tooth
            Ed




    Surgery to the mandibular third molar is common,

                                                           roots and the inferior alveolar canal (IAC), intraopera-
    and injuries to the inferior alveolar nerve and the

                                                           tive exposure of the nerve trunk, less-experienced
    lingual nerve are well-recognized complications

                                                           surgeon, use of the lingual split surgical technique,
    of this procedure. The aim of these technical

                                                           use of rotary instruments for bone removal or tooth
    notes is to describe operative measures for re-

                                                           sectioning and compression of the nerve during root
    ducing neurological complications during mandi-

                                                           elevation (1-5). In addition to increasing age, deep
 IC




    bular third molar surgery.

                                                           and distal impaction, and the use of the lingual split
    The following procedure should be used to pre-

                                                           technique, the risk factors for LN involvement have
    vent damage to the inferior alveolar nerve: a well-

                                                           been mainly related to iatrogenic causes such as
    designed mucoperiosteal flap, to obtain appropri-

                                                           poor flap design, using a periosteal elevator to raise
    ate access to the surgical area; a conservative os-
C




                                                           and retract the lingual flap, clumsy instrumentation,
    tectomy on the distal and distal-lingual side;

                                                           and iatrogenic fracture of the lingual plate (1, 6-8).
    tooth sectioning, to facilitate its removal by de-

                                                           Nerve damage may also be related to trauma during
    creasing the retention zones; tooth dislocation in

                                                           the injection of a local anaesthetic nerve block, intra-
    the path of withdrawal imposed by the curvature
©




                                                           operative haemorrhage or post-operative complica-
    of the root apex; and careful socket debridement,

                                                           tions including swelling, haemorrhage and perineural
    when the roots of the extracted tooth are in inti-

                                                           inflammation (5, 9). Damage to the IAN causes hy-
    mate contact with the mandibular canal.

                                                           poaesthesia, anaesthesia, paraesthesia or dysaes-
    To prevent injury to the lingual nerve, it is impor-

                                                           thesia of the lower lip, chin, teeth and buccal mucosa
    tant (I) to assess the integrity of the mandibular

                                                           on the homologous side, whilst altered sensations of
    inner cortex and exclude the presence of fenes-
    tration, which could cause the dislocation of the

    Annali di Stomatologia 2017;VIII (2):45-52                                                                    45
    G. La Monaca et al.




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                                                                               az
                                                                             rn
    Figure 1. (a) Panoramic radiograph shows impaction of 4.8 in the presence of the overlap of root tips and inferior alveolar
    canal; (b) CT cross-sections demonstrate the exact course of the mandibular canal in contact with the roots of 4.8.


    the tongue are due to LN lesions (1). Furthermore,
    depending on the involved nerve and the severity of
                                                           te       third molar involves anaesthesia, incision and eleva-
                                                                    tion of mucoperiosteal flap, ostectomy and tooth sec-
                                                         In
    the damage, there may be an association with func-              tioning, elevation and avulsion according to the root
    tional deficits, such as burning sensation of the               axis, socket debridement, and suturing. These vari-
    tongue, chewing and speech difficulties, involuntary            ous procedures are described in detail below.
    biting of the lip and/or tongue, and dysgeusia (7, 9,           Local anaesthesia is generally preferred, and can be
    10). To minimize intra- and post-operative neurologi-           induced using an IAN block (mepivacaine 3% without
                              ni

    cal complications, a preoperative radiological exami-           epinephrine) and tissue infiltration (mepivacaine 2%
    nation is mandatory for assessing the presence of               with 1:100,000 epinephrine). General anaesthesia
    risk factors and to decide on the most appropriate              could be restricted to patients who are not coopera-
                            io


    surgical technique. Panoramic radiography is most               tive, long or complex interventions, or when there is a
    commonly used for this purpose, but this method                 high risk of intraoperative complications requiring fur-
    does not reveal (I) the true relationship between the           ther treatment, such as jaw fractures.
                          iz



    IAC and third molar in the presence of the overlap of           A well-designed mucoperiosteal flap for obtaining ap-
    root tips and IAC; (II) diversion, narrowing or interrup-       propriate surgical access is the most important step
    tion of the IAC; (III) curvature, darkening, deflection or      in the removal of impacted mandibular third molars. A
           Ed




    narrowness of the roots; or (IV) a bifid root apex (Fig.        triangular or linear buccal flap is likely to be optimal.
    1a) (5, 10-14). Computed tomography is recommended              In this type of flap, to preserve the integrity of the LN,
    in these cases for demonstrating the three-dimensional          a distal releasing incision should be made in the
    relationship between the two structures due to its sensi-       retromolar area from the dista-buccal crown edge of
    tivity and specificity both being significantly superior to     the second molar slightly oblique in the vestibular di-
    panoramic images (11). Indeed, the additional informa-          rection, without involving the lingual side of the cre-
 IC




    tion provided regarding the position of the third molar         stal mucosa. The mucoperiosteal flap must be elevat-
    and on the nerve and root anatomy makes it possible to          ed on the buccal surface of the mandible, and eleva-
    improve the surgical approach and reduce the risk of            tion of the lingual soft tissues, which is usually limited
    injury (Fig. 1b) (5, 15-19). However, this method cannot        to a few millimetres, should be performed carefully in
C




    be used to localize the LN.                                     order to prevent accidental slippage of the periosteal
    The purpose of this article is to describe operative            elevator (Fig. 2).
    protocols that should minimize the risk of damage to            When the third molar position requires a lingual flap,
    the IAN and LN during mandibular third molar                    it should be wide enough to allow adequate access to
©




    surgery.                                                        the operating field, and the releasing incision should
                                                                    be located some distance from the site of inclusion,
                                                                    within the safety zone, to avoid unintended traction or
                                                                    lacerations of the LN. Before and after raising and re-
                                                                    tracting the subperiosteal lingual flap using a curved
    Surgical technique

    The surgical approach for removing the mandibular               periosteal elevator, a lingual broad retractor with no

    46                                                                                  Annali di Stomatologia 2017;VIII (2):45-52
    Prevention of neurological injuries in third molar surgery: technical notes




                                                                                                          li
                                                                                                        na
                                                                                                      io
                                                                                az
                                                                              rn
    Figure 2. Mucoperiosteal flap: the distal releasing incision in the retromolar area should not involve the lingual side of the
    crestal mucosa.


    sharp edges must be placed carefully in the perios-
    teum and the bone plate in order to improve visibility
                                                            te
                                                          In
    and to protect the lingual soft tissue and the LN dur-
    ing ostectomy, tooth sectioning and elevation (20,
    21).
    Ostectomy is usually carried out from the occlusal
    plane down to the cemento-enamel junction of the
                                ni

    mandibular third molar, and it should be as conserva-
    tive as possible on the distal and distal-lingual side so
    as to not involve the IAN and LN (Fig. 3) (22). To
                              io


    avoid thermal trauma, the bone tissue should be re-
    moved using tungsten-carbide round and fissure burs
    mounted on a low-speed handpiece under copious
                            iz



    refrigerated irrigation (4).
    Tooth sectioning is designed to allow disengagement
    of the element by decreasing its zone of retention and
            Ed




    to avoid compression or stretching of the IAN. The
    sectioning performed using a tungsten-carbide round
    bur mounted on a high-speed handpiece should not
    exceed the peripheral limits of the tooth, so as to
    leave a thin diaphragm of intact dental tissue near the
    nerve trunk. In order to complete the sectioning pro-
 IC




    cedure, the diaphragm will be fractured in a cautious
    manner using elevators (Fig. 4).
                                                                     Figure 3. Ostectomy: should be as conservative as possi-
    Tooth removal should be performed with a root eleva-
                                                                     ble on the distal and distal-lingual side.
    tor, directing the force vector in the path of withdrawal
C




    imposed by the curvature of the root apex, to avoid
    the risk of nerve compression or stretching.
    Socket debridement is performed after tooth extrac-              Suturing in the retromolar pad area should be per-
    tion with extreme care, especially when removing the             formed with the needle piercing the mucosa from
©




    lingual portion of the follicular remnants from sur-             the inner side in a buccal-lingual direction, because
    rounding tissues to avoid tearing the lingual mucosa             a passage in the opposite direction could expose
    so as to not damage the LN. The socket was then irri-            the LN to the risk of a puncture lesion and to injury
    gated with sterile saline solution at room temperature           due to its shrinkage during the knotting procedure
    (Fig. 5).                                                        (Fig. 6).


    Annali di Stomatologia 2017;VIII (2):45-52                                                                                 47
    G. La Monaca et al.




                                                                                                      li
                                                                                                    na
                                                                                                  io
                                                                            az
                                                                          rn
    Figure 4. Tooth sectioning is designed to allow disengagement of the element by decreasing its zone of retention and to
    avoid compression or stretching of the IAN.




                                                         te
                                                       In
                              ni
                            io
                          iz
           Ed
 IC




    Figure 5. Socket debridement is performed with extreme
    care, avoiding to tear the lingual mucosa not to damage
    the LN.
C




    Discussion

    Different surgical techniques have been described for
©




    preventing neurological injury during mandibular third        Figure 6. Suturing in the retromolar pad area should be
    molar surgery. Coronectomy (partial odontectomy or            performed with the needle piercing the mucosa from the in-
    root retention) consists of removing only the crown of        ner side in a buccal-lingual direction not to expose the LN
    an impacted mandibular third molar, leaving part of           to the risk of puncture and shrinkage lesions during the
    its roots at least 3 mm below the crestal bone, and           knotting procedure.


    48                                                                                Annali di Stomatologia 2017;VIII (2):45-52
    Prevention of neurological injuries in third molar surgery: technical notes


    without performing pulpal treatment (23, 24). Coro-             can reduce neurological complications.
    nectomy seems a reliable procedure for reducing the             Regarding the type of anaesthesia, some Authors
    incidence of injuries to the IAN (0-9.5%) and LN (0-            have found the incidence of nerve damage to be low-
    2%), with low rates of post-operative failure (on aver-         er and the neuropathic area to be larger when the
    age less than 10%) and post-operative complications             surgery is performed under general rather than local
    (pain, swelling, infection, dry socket and root migra-          anaesthesia (10, 32). This could be due to the in-
    tion) (23, 25, 26). In some cases, accidental intraop-          creased difficulty of specific surgical procedures and




                                                                                                      li
    erative loosening or mobilization of the roots and              to the aggressiveness of the surgeon when an inter-




                                                                                                    na
    post-operative root exposure made it mandatory to               vention was carried out with the patient under general
    perform conventional surgical extraction. However,              anaesthesia (10). In a single prospective study of 718
    this technique is considered controversial by many              mandibular third molar extractions, Brann et al. found
    oral surgeons due to the potential adverse effects of           that the incidence of LN and IAN damage was five
    the retained roots. New randomized clinical studies             times higher when the surgery was performed under




                                                                                                  io
    involving larger samples and long follow-up periods             general anaesthesia (18%) than under local anaes-
    are needed to accurately assess the long-term suc-              thesia (3%). However, they found no significant asso-
    cess of this approach.                                          ciations between surgical difficulty, eruption status,




                                                                               az
    The orthodontic-assisted extraction requires surgical           age and preoperative pathology (32). In contrast, the
    exposure of the third molar crown, placement of an              prospective longitudinal study of Rehman et al. found
    orthodontic anchorage and orthodontic extrusion in              no links between the choice of local (105 teeth) or
    order to move the roots away from the IAC; the ex-              general (474 teeth) anaesthesia and nerve damage




                                                                             rn
    traction is then performed after 3-6 months, when the           during the removal of 614 mandibular third molars
    tooth has moved sufficiently in the occlusal plane (27-         when the difficulty of surgery was taken into account
    29). Although this technique can improve periodontal            (33).
    healing distal to the second molar, it has disadvan-            Nerve damage can also occur as a complication of




                                                           te
    tages of being complex to perform, not well tolerated           mandibular block anaesthesia, which affects the LN
    by the patient due to discomfort of the orthodontic de-         significantly more often than the IAN (34, 35). Al-
    vice, time-consuming and expensive (25).                        though the reasons are unknown, the sensory alter-
                                                         In
    Another procedure requiring a double surgical inter-            ations reportedly occur due to direct trauma by nee-
    vention is the staged approach, which involves sec-             dle during penetration or retraction from bone con-
    tioning the mesial portion of the third molar crown to          tact, compression by intraneural bleeding or neuro-
    provide adequate space distal to the second molar to            toxicity of certain anaesthetic formulations (e.g. 4%
    promote migration of the roots away from the IAN,               articaine and 3-4% prilocaine). To prevent nerve in-
                                ni

    which are extracted in the second surgical session              juries related to local anaesthesia, high concentra-
    (30). We consider that compared with the orthodon-              tions of anaesthetic agent and multiple blocks should
    tic-assisted technique, this technique improves pa-             be avoided whenever possible (10).
                              io


    tient comfort and reduces the chair time and procedu-           The flap design was planned preoperatively accord-
    ral costs, since no intraoral appliances are required           ing to the depth of the inclusion and the position of
    (30).                                                           the third molar. During flap incision it is important to
                            iz



    Pericoronal ostectomy also consists of two stages to            avoid both the LN and facial artery. In the mandibular
    complete the extraction of the third molar. In stage 1,         third molar region, the LN runs about 2.5 mm medial-
    pericoronal bone is removed to eliminate bony inter-            ly and inferiorly to the alveolar ridge, although in
            Ed




    ferences and create an adequate “eruptive space” to             some cases it may lie above the bone or within the
    allow occlusal movement of the tooth, with light luxa-          soft tissues of the retromolar pad area (36, 37).
    tion (subluxation) of the tooth to improve its eruptive         These variations in the position of the LN predispose
    potential; this is followed some weeks later by extrac-         it damage throughout the surgical procedure, and in-
    tion in stage 2 (31). The drawbacks of this procedure           juries are not always avoidable (6).
    are the involvement of a staged operation, the possi-           Once flap incision and dissection are completed, it is
 IC




    bility of LN injury in rare cases necessitating the full        important to keep the soft tissue retracted and pro-
    exposure of the coronal surface at the lingual aspect           tected during ostectomy, tooth sectioning and dislo-
    and a (low) risk of IAN injury (31). The use of this            cation. Several studies have shown that while the use
    staged approach and pericoronal ostectomy is actual-            of a lingual flap and the placement of a lingual retrac-
C




    ly based on a very small sample with a short follow-            tor can cause transient LN damage, this procedure
    up, and so its effectiveness and safety still need to be        does not appear to be a cause of permanent LN dam-
    comprehensively assessed in randomized controlled               age (38, 39). Many studies have criticized the use of
    trials involving large samples.                                 a Howarth elevator, since although this can be used
©




    Alternative surgical techniques have been proposed              to retract the lingual tissue, it does not adequately
    for the removal of mandibular third molars, but the             protect the LN, and the bur can slip in front or behind
    conventional surgical extraction with a buccal ap-              the elevator and still damage the LN (40). Moss et al.
    proach remains the most common procedure world-                 proposed that the key to successful lingual retraction
    wide. We consider that the technical notes described            was creating an area of “tissue freedom” before in-
    in this article suggest intraoperative measures that            serting a retractor in order to avoid unnecessary

    Annali di Stomatologia 2017;VIII (2):45-52                                                                           49
    G. La Monaca et al.


    stretching of the nerve. This theory suggests extend-
    ing the lingual flap to the distal side of second molar
                                                               Conclusion

    to allow the insertion of a wider retractor, a technique   Minimizing intra- and post-operative neurological
    that reportedly resulted in a lower incidence rate in a    complications requires a good knowledge of anatomy
    single operator series (41). Where necessary, the use      in order to identify the presence of risk factors and to
    of a lingual retractor provides the surgeon with better    decide on the most appropriate surgical technique.
    visualization of the third molar, better access and the    The role of expertise and professional experience in




                                                                                                        li
    ability to remove distal bone, distal-lingual bone and     the incidence of complications associated with third




                                                                                                      na
    even lingual bone, since protection is provided by re-     molar removal should also not be underestimated,
    tractor. Raising a lingual flap and using a lingual re-    since complications reportedly occur more often
    tractor for selected indications is therefore felt to be   among inexperienced surgeons than among those
    an acceptable protocol during the removal of               with experience related to IAN and LN injury (6, 20,
    mandibular third molars (6, 24). Note that the lingual     38-40, 45, 47). However, some Authors have also




                                                                                                    io
    retractor must be broad and have no sharp edges to         found higher rates of IAN deficits in surgery per-
    ensure that the LN is protected and not damaged (2).       formed by specialists/consultants than surgical
    The ostectomy was always performed under copious           trainees/residents or undergraduates (1, 33, 45). Le-




                                                                          az
    irrigation to prevent overheating and using new and        ung and Cheung assumed that the greater involve-
    sharp burs. There are some reports of higher rates of      ment of specialists/consultants in post-operative IAN
    IAN and LN damage after extraction of third molar          deficits could be due to them encountering more diffi-
    with total bone impaction, because damage to these         cult and deeply impacted third molars compared with




                                                                        rn
    nerves is significantly related to the technique used      the operators having less surgical experience (1).
    for bone removal (3, 6, 9, 41).                            This research did not receive any specific grant from
    To reduce surgical morbidity caused by manipulation        funding agencies in the public, commercial, or not-
    and to minimize damage during ostectomy, the tooth-        for-profit sectors.




                                                        te
    sectioning technique is a standard procedure that fa-
    cilitates the removal of the impacted tooth by de-
    creasing its zone of retention (4). Ultrasound bone
                                                      In       Conflict of interest and source of funding
    surgery may also be useful in selected cases for re-       statement
    ducing the risk of nerve damage during ostectomy
    and tooth sectioning. This technique can be used to        The Authors have stated explicitly that there are no
    make micrometric, precise and smooth cuts into min-        conflicts of interest in connection with this article.
    eralized tissues while adjacent soft tissues are pre-
                              ni

    served, provided that very low pressure is applied
    (42-44). Nevertheless, the operating time is much
                                                               All Authors gave final approval and agree to be ac-
                                                               Authors Declarations
    longer compared to when using conventional rotary
                            io


    instruments.                                               countable for all aspects of the work.
    It must also be remembered that inappropriate tooth
    dislocation may cause the displacement of the entire
                          iz



    tooth or part thereof into the sublingual or submandi-
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                                                                    in lower third molar surgery: an literature review of prospec-
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                                                                    tors. J Can Dent Assoc. 2007;73:325.
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                                                                    Oral Radiol Endod. 2010;109:294-302.
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          1997;84:345-358.                                                          chi L. Orthodontic extraction: riskless extraction of impact-
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