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One of the most common complication associated with oral surgical procedures are iatrogenic injuries to lingual branch of trigeminal nerve. Lingual nerve damage may result in permanent lingual sensory deficit leading to symptoms, including lost or altered sensation and the development of unpleasant neuropathic pain, with consequent impaired quality of life. The surgical removal of mandibular third molars is one of the most common oral surgical procedures and it is associated with a number of perioperative complications, including nerve injuries. This paper show how to manage lingual nerve injuries.
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Management of lingual nerve injury: a case report
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                                                                                                                  Case report


     Management of lingual nerve injury: a case report


     P. Tiriduzzi1                                                  and sublingual salivary glands, the latter follow the fibers
     L. Gentili                                                     of the lingual nerve to the taste buds. Once separated
     C. Vianale                                                     from the mandibular nerve, it runs between the internal
     M. Coloccini                                                   pterygoid muscle and the medial wall of the mandibular
     M. Messi M.                                                    ramus. At the retromolar trigone and molar (particular-
                                                                    ly the third) level, the nerve runs on the upper medial
                                                                    margin of the alveolar ridge and can be very superficial.
     1
         U.O.C. (Complex Operative Unit) Oral Surgery & Odon-       The LN then runs into the oral floor and terminates in the
         tostomatology A.V.2 Ancona (Provincial Administration)     lingual pelvis (1).
         - A.s.u.r. (Regional Healthcare Agency) Marche, Italy.     Anatomical studies of the LN mainly focus on its course
                                                                    at the oral cavity floor and the retromolar trigone level,
                                                                    as it is most susceptible to injury during surgical proce-
     Corresponding author:                                          dures (2-6). In a cadaver dissection study, 669 LNs were
     Dr Paolo Tiriduzzi. paolo.tiriduzzi@gmail.com                  analyzed. 14.05% were located above the lingual crest,
                                                                    0.15% in the retro molar trigone and 85.80% in the typ-
                                                                    ical position, i.e. at a vertical distance from the lingual
                                                                    crest of 3.01±0.42 mm and at a horizontal distance from
     Neurological lesions of the lingual nerve (LN), during         the lingual plate of 2.06 ± 1.10 mm (7).
     general dentistry and oral surgery practice, are still fre-    In its typical position, the LN, in 23.27% of the cases, is
     quent nowadays, despite the existence of three-dimen-          directly in contact with the lingual plate of the alveolar
     sional diagnostic radiology, stereolithography, up-to-date
                                                                    process. However, when the LN is located in the retro-
     surgical techniques and instruments with sonic and pie-
                                                                    molar area, it runs between the mandibular ramus and
     zoelectric technology resulting in a gentler treatment of
                                                                    the medial pterygoid muscle, instead of proceeding in
     soft tissues.
                                                                    its normal course along the medial surface of the mandi-
                                                                    ble and lying near the roots of the third molars. It heads
     Abstract                                                       towards the retromolar trigone, then it runs posterior to
                                                                    the third molar and, finally, it descends at an acute angle
     One of the most common complication associated                 in the direction of the medial surface of the mandible,
     with oral surgical procedures are iatrogenic injuries          resuming its normal course (8).
     to lingual branch of trigeminal nerve. Lingual nerve
     damage may result in permanent lingual sensory
     deficit leading to symptoms, including lost or altered
     sensation and the development of unpleasant neuro-
                                                                    Aetiology of lingual nerve injury
     pathic pain, with consequent impaired quality of life.         The most frequent cause of LN lesion is to be sought
     The surgical removal of mandibular third molars is             in the extraction surgery of the lower third molars: LN
     one of the most common oral surgical procedures                is, in fact, damaged during 0.6-2% of extractions of
     and it is associated with a number of perioperative            these tooth elements (9, 10). However, implant surgery,
     complications, including nerve injuries. This paper            removal of calculi from the Warton’s duct, treatment of
     show how to manage lingual nerve injuries.                     ranula located in the postero-lateral portion of the mouth
                                                                    floor, removal of mandibular cysts, of impacted or su-
                                                                    pernumerary teeth, of benign lesions or demolition for
     Keywords: lingual nerve injury, third molar extrac-
                                                                    malignant neoformations, orthognathic surgery, osteora-
     tion, paresthesia, neurorrhaphy.
                                                                    dionecrosis, osteomyelitis and maxillofacial trauma may
                                                                    also be among the causes of LN injury (11, 12).
                                                                    Performing truncular anaesthesia can also cause neuro-
                                                                    logical injury. The incidence of temporary injuries of the
     Anatomy                                                        LN following the performance of truncular anaesthesia
     The LN is a sensory branch of the third trigeminal branch      ranges between 0.15% and 0.54%, while permanent
     and provides tactile and thermal sensitivity of the oral       ones range 0.01% approximately (13, 14).
     floor and the anterior two-thirds of the tongue. This nerve    The etiopathogenetic mechanism may be related to a
     also distributes the visceral efferent and visceral afferent   needle injury, to the potential neurotoxicity of the anaes-
     fibers of the intermediate facial nerve transmitted through    thetic agent and its ischaemic effect with possible subse-
     the chorda tympani: the former reach the submandibular         quent degeneration of axons (15).


12                                                                                     Annali di Stomatologia 2021; XII (1-4): 12-21
P. Tiriduzzi et al.

Classification of nerve injuries                               Symptomatology of neurological lesions
The most widely used classification for assessing neu-         The International Association for the Study of Pain
rological impairment is Seddon’s classification of 1943,       (IASP) distinguishes the symptoms resulting from a
which identifies three types of nerve injury:                  nerve injury into:
- Neuropraxia: consisting of a conduction block, re-           - Anaesthesia: complete absence of sensitivity in the
     lated to compression or stretching of a nerve trunk           innervation territory.
     during surgery or postoperative perineural edema.         - Paresthesia: altered sensitivity.
     Stimulating the axon in the proximity of the lesion       - Hypoesthesia: a decrease in normal sensation (to
     causes no distal response, while stimulation down-            either tactile, thermal and painful stimuli).
     stream gives a completely normal response. Neu-           - Hyperesthesia: an abnormal increase in sensitivity
     roapraxia allows spontaneous and relatively rapid             to stimuli. In the case of a painful stimulus, it is de-
     healing.                                                      scribed as hyperalgesia.
- Axonotmesis: characterized by anatomical inter-              - Dysesthesia: altered sensitivity associated with burn-
     ruption of the axons, while preserving the nerve              ing/pain. This sensation, most unpleasant for the
     sheaths. The distal nerve stump undergoes Wal-                patient, can be either spontaneous or triggered by a
     lerian degeneration, while the proximal stump de-             stimulus that is not typically pain-inducing (Allodynia).
     generates as far as the first node of Ranvier. Nerve          The altered sensitivity of the tongue involves only the
     regeneration is possible and restarts from the intact         affected half that is related to the injured nerve. The
     proximal stump at a rate of about 1 mm per day, fol-          patient reports a feeling of “swollen tongue” deter-
     lowing the guide shown by the intact nerve sheaths.           mining eventual discomfort: a frequent morsicatio of
     Functional recovery can be achieved upon com-                 the lingual margin with consequent traumatic lesions,
     plete regeneration. However, it may also require a            while the decreased proprioceptive capacity with-
     few months.                                                   in the oral cavity may compromise food distribution
- Neurotmesis: consisting of interruption of both the              between the dental arches and the act of deglutition,
     axons and the nerve sheaths. In this way, sponta-             phonatory difficulty, and partial taste alteration. When
     neous regeneration is not possible and surgery is             the main symptom is pain, and not anaesthesia, the
     required (16-18). In 1951, Sunderland considered it           quality of life is greatly impaired because the patient
     appropriate to divide axonotmesis into two degrees            experiences spontaneous pain despite the absence
     of severity, based on the nerve’s ability to recover          of tactile and gustatory sensitivity of the tongue.
     full or partial function, and neurotmesis into two fur-
     ther levels, based on the continuity or discontinuity     Timing and injury management
     of the nerve, thus proposing a classification into five
     degrees of injury (19). In 1989 Mc Kinnon added a         In the case of a confirmed LN injury, there are two pos-
     sixth degree, in relation to an injury involving sever-   sibilities. The first is the immediate repair, through micro-
     al fascicles in the same nerve (20).                      surgical procedure, of the iatrogenic damage occurred
The patterns of LN injury in oral surgery are hetero-          accidentally during another scheduled treatment. This
geneous and depend on both the type of surgery per-            particular situation requires the surgeon to be skilled in
formed and the instruments used. They can be sum-              microsurgery, as well as the available suitable instru-
marized into a few groups: compression damage,                 mentation, high-magnification loupes, or, even better,
stretch-induced damage, partial or complete resection          a surgical microscope. In addition, it is essential to be
damage. Compression of the LN can occur as a direct            able to perform the surgery under balanced general an-
consequence of an improper use of surgical instru-             esthesia, in order to ensure complete anesthesia of the
ments such as retractors, elevators, malleable spatu-          affected nerve and immobility of the patient throughout
las, specifically employed to protect this nerve struc-        the procedure. If the above conditions are not feasible,
ture. The prognosis is generally good and restitutio ad        the microsurgical repair should be performed as soon as
integrum usually occurs within a couple of weeks to a          possible, preferably within a month.
couple of months.                                              However, it is not always possible to make an immedi-
Stretch injury is caused by the traction of the nerve          ate diagnosis of a confirmed LN injury, as such an inci-
along its major axis and the consequent extension of           dental event may occur during noninvasive procedures.
the same nerve. In this case, the resolution of symptoms       The pain felt by the patient in the intraoperative phase
may occur within 6 months. Partial and total resections        is therefore often mistaken for a failure of local anaes-
occur through accidental trauma with surgical instru-          thesia during dental treatment, thus making it difficult to
ments or through displacement of the lingual plate of the      diagnose neurotmesis from compression or stretch. In
alveolar process, e.g. during extraction of mandibular         addition, it is often the patient, during the days following
third molars. In the case of partial resection, recovery,      the treatment, who reports to the dentist discomfort or
albeit partial, may require up to 12 months. On the con-       altered sensitivity of the tongue.
trary, a clean cut of the nerve results in the formation of    Once the diagnosis of nerve damage has been made,
two stumps, and the prognosis is poor, as spontaneous          a follow-up period of at least three months is needed in
functional recovery is not possible. This is due to the re-    order to assess any possible improvement in the symp-
traction of the two stumps and the frequent formation of       tomatology, or to decide if surgical procedure is neces-
an amputation neuroma near the proximal stump, com-            sary. During the follow-up period, subjective assessment
posed of axonal fibers and scar tissue, which generates        tests of sensitivity should be performed, stimulating the
spontaneous pain or touch-evoked pain.                         tongue with pressure stimuli at different points and re-

Annali di Stomatologia 2021; XII (1-4): 12-21                                                                                  13
     Management of lingual nerve injury: a case report

     cording any eventual improvement. If the anaesthesia              subsequent pain and sensation loss of the auricle. To
     does not disappear after 3 months or if the hypoaesthe-           overcome these problems, it is possible to employ a
     sia does not improve within 8 months, surgical treatment          homologous graft, using a deantigenated and sterilised
     of the lesion should be considered (21).                          donor-derived nerve tissue that, while maintaining the
     The repair of nerve damage in case of anaesthesia can             natural epineural sheath, acts as a scaffold for possible
     be performed using different techniques, depending on             guided axonal regeneration (22-28).
     the overall clinical situation.                                   A further possibility is the use of synthetic biological con-
     The neurorrhaphy technique consists of reconstructive             duits and guides (first generation), resorbable collagen
     suture of the two nerve stumps. There are four types of           type I conduits (second generation), or conduits contain-
     peripheral nerve reconstruction: epineural, perineural,           ing stem cells (third generation) which are currently being
     epi-perineural and fascicular suture. Neurorrhaphy is             studied and tested (29, 30). When painful symptoms of
     performed using epineural sutures, in a circumferential           severe dysesthesia without regression occur a few weeks
     manner. The lingual nerve, in fact, has a diameter rang-          after the traumatic event, intervention by performing neu-
     ing from 1.5 to 3 mm and the individual nerve fascicles           rolysis is necessary. This consists of freeing a compressed
     are not distinguishable within it. Therefore, perineural          nerve from a pathological adhesion, e.g. scar tissue, to
     or fascicular suture cannot be performed. Such proce-             allow the recovery of its functionality. There are two tech-
     dures are more suitable for larger nerves or well-defined         niques of neurolysis. Troncular neurolysis is a procedure
     nerve bundles, as for example the brachial plexus. The            that involves the liberation of the nerve from compression
     suture of the two nerve ends must be performed without            alongside its entire circumference. It is performed when
     any tension with 8-0 sutures made of a perfectly toler-           the nerve is suffused with fibrous tissue attributable to an
     ated and non-absorbable material, in order to avoid for-          injury in neighboring tissues. Fascicular neurolysis is per-
     eign-body reactions along with scarring and subsequent            formed on an injured nerve visualized under a microscope
     failure of the procedure.                                         and consists of removing the fibrous tissue surrounding
     Once the two nerve ends have been identified among                each individual filament.
     the soft tissues, obtaining a tension-free juxtaposition
     should not be very complex, as it is possible to slide            Management of lingual nerve injury:
     them and reapproximate the two ends. It must be con-              Case report
     sidered that at the lesion site there may be a neuroma,
     either traumatic or resulting from amputation, which              T.I., a 30-year-old female patient, underwent an extrac-
     must necessarily be resected, in order to allow the juxta-        tion surgery of the mandibular lower left third molar un-
     position of the two ends with exposed healthy non-scar            der local anaesthesia (Fig. 1). During the extraction, the
     tissue. This manoeuvre may not allow the execution of a           distal root of the lower left third molar was accidentally
     tension-free suture and make it necessary the use of a            dislocated into the soft tissue on the lingual side. After
     connecting graft.                                                 attempting an intra-alveolar recovery of the remnant, the
     The graft used may be autologous and taken from the               procedure was suspended and a suture performed, as
     greater auricular nerve. This technique involves an in-           a significant amount of time had passed since the ex-
     crease in surgical time, greater morbidity in the patient,        traction. In addition, the excessive bleeding of the site
     possible formation of a neuroma at the donor site with            and the consequent impossibility of having a clear view




     Figure 1. Preoperative orthopantomography of the lower left third molar extraction surgery.

14                                                                                        Annali di Stomatologia 2021; XII (1-4): 12-21
P. Tiriduzzi et al.

to identify the fragment, the increase in perceived pain,         cial Administration) of Ancona where she was exam-
the consequent state of agitation of the patient and the          ined. The objective oral examination revealed injuries
increasing stress for the dentist, led to a picture that was      from biting. Moreover, complete lack of sensitivity of
no longer manageable in an outpatient dental clinic envi-         the left tongue was ascertained using the three assess-
ronment of basic level.                                           ment tests: puncture test, tactile test and proprioceptive
The days following the extraction, the patient immedi-            discrimination test. Dysesthesia and persistent burning
ately reported classic symptoms of anaesthesia of the             sensation also made normal oral hygiene manoeuvres
tongue in the left side, followed by periods of dysesthe-         painful for the patient. A CTA and a new orthopanto-
sia and burning. However, she was treated for the first           mography were conducted (Fig. 2). Radiographic ex-
six months using NSAIDs, cortisone, and B-complex                 aminations showed the presence of the root remnant
vitamins, probably hoping for a resolution of the dam-            and a discontinuity of the lingual alveolar wall of the
age despite the root remnant being dislocated in the soft         lower left third molar (Fig. 3-8). Surgery to remove the
tissues.                                                          root remnant, along with the concomitant attempt to
The patient arrived at the U.O.C. (Complex Operative              repair the nerve lesion, was then scheduled under bal-
Unit) of Oral Surgery and Odontostomatology A.S.U.R.              anced general anaesthesia, although the recommend-
Marche (Regional Healthcare Agency), A.V. 2 (Provin-              ed timing had already passed.




Figure 2. Postoperative orthopantomography of the lower left third molar extraction surgery.




                                                                                                Figure 3. CBCT.

Annali di Stomatologia 2021; XII (1-4): 12-21                                                                                  15
     Management of lingual nerve injury: a case report




                                                                    Figure 4. CBCT.




                                                                    Figure 5. CBCT.




                                                                    Figure 6. CBCT.

16                                                       Annali di Stomatologia 2021; XII (1-4): 12-21
P. Tiriduzzi et al.




Figure 7. CBCT.




Figure 8. CBCT.

Annali di Stomatologia 2021; XII (1-4): 12-21   17
     Management of lingual nerve injury: a case report

     Once the state of narcosis had been induced, the left              the upright branch of the mandible and part of the root
     retromolar trigone and the left oral floor, both distally and      remnant up to the premolar region.
     mesially, were infiltrated with adrenaline to achieve opti-        At first, the root remnant had to be located through the
     mal bleeding control (Fig.9).                                      soft tissues by the maxillofacial surgeon, who dissected
     A full-thickness incision was performed using an electro-          them using blunt dissection technique. Once located, the
     surgical unit, in the attempt to follow, as much as possi-         fragment was removed by a Klemmer forcep (Fig.10-11).
     ble, the scars of the previous surgery. The surgical field         Performing again the atraumatic blunt dissection tech-
     was widened lingually in order to clearly expose part of           nique, the ends of the injured LN were isolated. The ma-




     Figure 9. Preoperative image.




     Figure 10. Operative phase of isolation and extraction of the dislocated root   Figure 11. Detail of the removed root remnant.
     in soft tissue.

18                                                                                        Annali di Stomatologia 2021; XII (1-4): 12-21
P. Tiriduzzi et al.

noeuvre proved to be complex, as the nerve had actually     sue constituting the amputation neuroma and free them
been cut in two parts, a diagnosis which was never cer-     from the fibrous tissue that covered them, surrounding
tain, because - as aforementioned - such lesion occurred    the neuroma. At this point microsurgical neurorrhaphy
during a noninvasive procedure, and this resulted in the    technique was performed using 8-0 polypropylene su-
consequent sliding and distancing of the two ends. In       tures (Fig. 12). After the subsequent washing of the
order to provide an effective recovery, an intraoperative   surgical field, the operation was terminated by suturing
microscope (under 16X magnification) was employed.          the flaps of the incision (Fig. 13). Once discharged, the
Once the two ends were identified, a few millimetres of     patient continued home treatment for three weeks, being
them were surgically removed to eliminate the scar tis-     administered antibiotic coverage therapy, together with




    Figure 12. Detail of the suture of the neurorrhaphy.




    Figure 13. Suture.

Annali di Stomatologia 2021; XII (1-4): 12-21                                                                           19
     Management of lingual nerve injury: a case report

     NSAIDs and corticosteroids anti-inflammatory therapy                on the ipsilateral lingual margin and dorsum, although
     and L-acetylcarnitine.                                              far from being considered a restitutio ad integrum, it al-
     Eight months have passed since the neurorrhaphy                     lowed her to resume normal chewing and physiological
     surgery was performed, and during check-ups the pa-                 tongue mobility (Fig. 14). A delayed intervention has
     tient no longer presents dysesthesia, hyperesthesia,                most certainly lowered the percentage of chances of a
     burning pains, and the traumatic biting lesions have                successful neurorrhaphy, nevertheless, performing this
     disappeared. Furthermore, she has resumed perform-                  type of surgery has eliminated all that algic symptoma-
     ing oral hygiene manoeuvres without any symptoms of                 tology reported by the patient and this, in neurology, can
     discomfort. She reports an improvement in sensitivity               be considered a success.




     Figure 14. Control at eight months after surgery.



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Annali di Stomatologia 2021; XII (1-4): 12-21                                                                                               21
