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Nerve Damage Wisdom Tooth
Nerve Damage Wisdom Tooth
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Oral Surgeon, Medical Officer(Dental),Government Dental College and Hospital, Jaipur, India.
Oral Diagnostician, Senior Dental Surgeon, Community Health Centre, Ramanagara, Karnataka, India.
ABSTRACT
Although third molar extraction is a routinely carried out procedure in a dental set up, yet it is feared both by the patient
and the dentist due to an invariable set of complications associated with it, especially in the form of nerve injuries.
Hence, prior to performing such procedures, it would be wise if the clinician thoroughly evaluates the case for any
anticipated complications so that adequate preventive measures can be taken to minimize the traumatic outcomes of the
procedure and provide maximum patient care, which would further save the clinician from any sort of litigation.
Key words: Lingual nerve, third molar extraction, nerve injury.
Introduction
The third molar extraction is quite commonly carried out surgical procedure in the oral cavity and it is not
uncommon for the dental practitioners to find their patients
in a state of dilemma whether to get the procedure done or
not. In such situations, apart from the pain of losing a tooth,
the patients fears centre on the pain, swelling and discomfort which might follow the procedure. A significant adverse impact on the oral health related quality of life has
been reported in patients who had experienced pain, swelling or trismus in the immediate postoperative period following lower third molar surgery. As far as mandibular third
molars are concerned, there may be various reasons, which
may justify their removal.
The indications for the removal of impacted wisdom teeth have been clearly established and were published in 1997 by the Faculty of Dental Surgery of the Royal
College of Surgeons of England, which enable a clinician
to easily decide upon whether to retain or to sacrifice the
third molars of their patients. The indications for extraction
include recurrent pericoronitis, cellulitis, abscess, osteomyelitis, cysts and tumors involving the third molars,
unrestorable caries or periodontal breakdown and prophylactic removal in the presence of medical or surgical conditions, among others. National Institute for Clinical Excellence (NICE) of England in March 2000 further, made an
endorsement of these guidelines with the added comment
that the first episode of pericoronitis, unless otherwise severe, should not be considered as an indication for removal.
(1)
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Andrew et al carried out a study in 2004 to determine the incidence of inferior alveolar nerve paraesthesia
in those patients where an exposed inferior alveolar nerve
bundle is seen during third molar surgery and it was concluded that such a situation hints a high probability of
intimate relationship of the nerve with the tooth and carries
a 20% risk of paraesthesia with a 70% chance of recovery
by one year from surgery. 1(13)
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uted to decreased nerve regeneration or neuronal plasticity. This latter hypothesis is supported by reports on the
effect of age on peripheral nerve regeneration and by the
fact that older patients, despite a macroscopically less traumatized IAN, show poorer recovery after mandibular osteotomies. (14)
Jozsef Szalma et al had also emphasized that advanced age is a risk factor for IAN injuries after third molar
extraction and mandibular osteotomies and also, the chances
of recovery are lesser in older patients. (9)
The technique used also determines to some extent the probability of injury to inferior alveolar or lingual
nerve. The literature mentions basically two approaches
for removing a mandibular impacted third molar namely, the
lingual split technique and splitting with a burr technique.
A great controversy exists regarding superiority between
the two mentioned techniques but however, the skill of
operator is another determining factor of the degree of nerve
damage.
Some authors have even suggested that
coronectomy should be preferred over extraction in patients
where there is radiological evidence of proximity of the
third molars with the inferior alveolar canal in order to avoid
any complications. However, Pogrel et al. noted that hollowing coronectomy and subsequent migration of the third
molar roots may be an issue in the long term. (16)
Rood et al in 1992 reported an incidence of 12.8%
of temporary lingual nerve dysaesthesia when using the
lingual split technique and only 2.3% when using drills.
However earlier in 1988 MASON had mentioned that there
was no difference when using either technique.(21, 19)
Yeh et al also did not find any single incident of
damage to the lingual nerve using the lingual split-bone
technique in their study.(22)
Considering that lingual nerve damage is the most
common event following lower third molar extractions, a
study was carried out to ascertain the impact of lingual
nerve protection in patients undergoing third molar
germectomy (i.e. removal of the developmental bud prior to
anchoring of the roots in the jaw). No lingual nerve injury
was observed after third molar germectomy regardless of
whether or not lingual nerve protection was used and so
the authors concluded that lingual nerve protection is unnecessary for lower third molar germectomy. Several other
reports have also been mentioned regarding the use of lingual retractors and rotating instruments during surgery.
Generally, minimal interference of the lingual soft tissues
during third molar surgery is associated with a lower inci-
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