Permanent damage to the lingual nerve during

mandibular third molar removal is not common.

Nevertheless, patients who have nerve injury may have
considerable disability. Injury to the lingual nerve
can result in anesthesia, paresthesia, dysesthesia, or
hypoesthesia.
1
Depending on the type and severity of
nerve disturbance, lingual nerve damage can cause
drooling, tongue biting, a burning sensation of the
tongue, burns on the tongue from hot food and drinks,
pain, change in speech pattern, and/or a change in taste
perception of food and drink.
2
Thus, even temporary
lingual nerve disturbances, which may last up to 6
months or longer, may be problematic for patients.
Third molar removal is one of the most common proce-
dures in the field of oral and maxillofacial surgery.
3
Nerve injury is a frequent reason for lawsuits against
dentists and oral and maxillofacial surgeons in the
United States.
4,5
In some countries, it is currently advocated that a
retractor be placed on the lingual bone when a third
molar is being removed to improve exposure of the
surgical field and protect the lingual nerve.
6
Various
types of lingual retractors, such as Howarths, Wards,
Meades, Hovells, and Rowes retractors, have been
used for this purpose.
6-8
Recently, attention has been
given to the safety of lingual flap retractors, some
studies focusing particularly on the narrow Howarths
periosteal elevator.
9-11
The lingual nerve can be within
1 mm of the boneessentially in the periosteumon
the lingual or distal side of the third molar and can be
damaged when a lingual flap is being reflected.
12,13
This study systematically reviews the incidence and
recovery of lingual nerve damage after the removal of
third molars by means of 3 different surgical tech-
niques, 2 of which involve the use of a lingual flap
retractor. An exhaustive, methodical literature review
was undertaken to identify all articles reporting injury
to the trigeminal nerve. These articles were reviewed to
single out those reporting injury to the lingual nerve
associated with the removal of mandibular third molars.
Reports that met specific inclusion criteria were then
analyzed in detail.
Lingual flap retraction and prevention of lingual nerve damage
associated with third molar surgery: A systematic review of
the literature
Jennifer W. Pichler, BS,
a
and O. Ross Beirne, DMD, PhD,
b
Seattle, Wash
UNIVERSITY OF WASHINGTON
Objective. Lingual nerve damage sometimes occurs after the removal of third molars. The use of a lingual retractor has been
advocated to protect the lingual nerve. A systematic review of the literature was undertaken to evaluate the incidence of
lingual nerve damage after third molar surgery and the effect of a lingual retractor on nerve damage.
Study design. An exhaustive computerized search of several databases and references cited in the various studies was
performed. Predetermined inclusion and exclusion criteria were used to identify the 8 published studies acceptable for
detailed analysis. The incidence and spontaneous recovery of lingual nerve injury for the following 3 surgical techniques were
evaluated: the buccal approach with lingual flap retraction (BA+), or the buccal approach without lingual flap retraction (BA),
and the lingual split technique with lingual flap retraction (LS).
Results. In the 8 selected articles, lingual nerve injury occurred in 9.6%, 6.4%, and 0.6% of the pooled LS, BA+, and BA
procedures, respectively. On the basis of risk ratios comparing combined incidence rates, lingual nerve injury is 8.8 times
more likely to occur in BA+ than in BA procedures (CI = 4.3-17.8), 13.3 times more likely to occur in LS than in BA proce-
dures (CI = 6.6-26.9), and 1.5 times more likely to occur in LS than in BA+ procedures (CI = 1.2-1.8). Permanent lingual nerve
injury occurred in 0.1%, 0.6%, and 0.2% of the combined LS, BA+, and BA procedures, respectively. The combined perma-
nent incidence risk ratios were not calculated because of the low permanent incidence rates.
Conclusions. The use of a lingual nerve retractor during third molar surgery was associated with an increased incidence of
temporary nerve damage and was neither protective nor detrimental with respect to the incidence of permanent nerve damage.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:395-401)
Supported in part by NIDCR Student Research Training Award No.
T35 DE 01750.
Presented as a poster at the IADR/AADR Annual Meeting,
Washington, DC, April 5-9, 2000.
a
Dental Student, School of Dentistry.
b
Professor and Chair, Department of Oral and Maxillofacial Surgery,
School of Dentistry.
Received for publication Jul 19, 2000; returned for revision Oct 4,
2000; accepted for publication Jan 4, 2001.
Copyright 2001 by Mosby, Inc.
1079-2104/2001/$35.00 + 0 7/12/114154
doi:10.1067/moe.2001.114154
395
METHODS
A computer search was performed through use of
MEDLINE, Healthstar, Current Contents, Allied and
Alternative Medicine, Life Sciences, Web of Science,
Nursing Allied Health, and Cochrane Library for all
years available up until May 1999. Searches combined
the words trigeminal nerve, mandibular nerve, inferior
alveolar nerve, lingual nerve, mental nerve, and dental
nerve with the words repair, surgery, reconstruction,
regeneration, spontaneous recovery, paresthesia, anes-
thesia, and dysesthesia (in all spellings), and with the
words neuropraxia, axonotmesis, and neurotmesis (in
all spellings). The indexes of the journal Oral and
Maxillofacial Surgery Clinics of North America for the
years 1989-1998 were individually searched to identify
related articles. A review of the references cited in these
articles yielded more studies, which were subjected to
reference searches as well. Each article was reviewed
through use of the following selection criteria: original
cases of lingual nerve damage caused by third molar
surgery reported with a follow-up of at least 6 months
or until full recovery. Six months was chosen as a
minimum follow-up period because patients with nerve
disturbances lasting longer than 6 months are unlikely
to fully recover.
14
Articles were excluded if the results
were not separately reported for each surgical method
or if the results were not based on clinical objective
sensory testing, such as light-touch or 2-point discrimi-
nation tests (Table I). Articles with fewer than 10 case
reports were excluded, and 3 articles with dupli-
cate study populations were also excluded. A log of
excluded studies and their reasons for exclusion was
kept. Forms were developed and used for collecting
data from the identified articles. Authors were contacted
for further information.
Because of the limited number of articles and the
differences in study designs, the use of statistical
methods for determining the presence of publication
bias and heterogeneity was not possible. With few
exceptions (Table II), nerve injury incidences were
assessed at approximately 1 week and were generally
considered permanent if sensory impairment remained
after 6 months. This factor allowed for comparisons of
incidences of lingual nerve injury after different
surgical techniques of third molar removal. Incidence
and spontaneous recovery of lingual nerve damage
were evaluated for 3 different surgical methods: the
buccal approach with lingual retraction (BA+), the
buccal approach without lingual retraction (BA), and
the lingual split technique with lingual retraction (LS).
The proportion of third molar surgical procedures that
caused lingual nerve injury was calculated for each
surgical method in each study; the combined totals for
each surgical method were also tabulated. Risk ratios
and their CIs were calculated for combined totals for
each surgical method. Risk ratios were calculated by
dividing the proportion of patients with nerve injury
from one surgical technique by the proportion of
patients with nerve injury for another second surgical
technique (RR = p
1
/p
2
). CIs for the risk ratios were
calculated as described earlier.
15
RESULTS
The computer searches yielded 542 potentially rele-
vant articles on trigeminal nerve damage in human
beings. A review of the reference lists in these articles
yielded another 197 articles, bringing the total to 739
articles. Because the inferior alveolar nerve is also
commonly affected by third molar surgery, a similar
analysis on this nerve was begun, but it was discon-
tinued because of a lack of studies meeting the inclu-
sion criteria.
An assessment of the articles yielded 85 articles with
original data pertaining to lingual or inferior alveolar
nerve injuries caused by third molar surgery. Fifty-one
articles included lingual nerve injuries; of these, 43
were excluded (Table I).
8,16-57
Eight published studies
with lingual nerve injury cases met the inclusion
criteria for detailed analysis (Table II).
10,11,58-63
The
main reasons for excluding articles on lingual nerve
injury after third molar removal were inadequate
follow-up and lack of sensory testing. The selected
studies represented the 16-year period from 1983 to
1999. Five of the 8 included studies originated in the
United Kingdom. Seven studies were prospective clin-
ical series, and 1 was a prospective randomized
controlled trial.
10
The 2 studies reported by Rood
44,62
in 1983 and 1992 involved different patient popula-
tions. Five studies used BA+ (n = 747 surgeries), 3
studies used BA (n = 1336 surgeries), and 3 studies
used LS (n = 2077 surgeries; Table III). All studies
carried out with a lingual flap retractor used Howarths
periosteal elevator.
The studies incidence rates and the combined totals
for each surgical method group are shown in Table III
and illustrated in Fig 1. Reported rates included all
forms of sensory disturbances, including hypesthesia,
paresthesia, dysesthesia, and anesthesia. Temporary
lingual nerve sensory disturbances occurred in 9.6%,
6.4%, and 0.6% of the combined LS, BA+, and BA
procedures, respectively. The risk ratio of the
combined temporary incidence for BA+ to that for
BA was 8.8 (CI = 4.3-17.8). The temporary incidence
risk ratio was 13.3 (CI = 6.6-26.9) for LS to BA and
1.5 (C = 1.2-1.8) for LS to BA+. All comparisons of
temporary nerve injury incidence rates among the 3
surgical methods were significant (P < .001). Permanent
lingual nerve sensory disturbances occurred in 0.1%,
396 Pichler and Beirne ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 2001
0.6%, and 0.2% of the combined LS, BA+, and BA
procedures, respectively. Risk ratios and CIs were not
completed for combined permanent incidences because
of the low incidence rates.
DISCUSSION
The data support the conclusion that the use of a
lingual nerve retractor during third molar surgery was
associated with an increased incidence of temporary
nerve damage and was neither protective nor detri-
mental with respect to the incidence of permanent
nerve damage. Robinson and Smith,
10
whose study
was the only randomized controlled trial that met our
inclusion criteria, had the same results. All studies
show a higher incidence of temporary lingual nerve
injury than permanent lingual nerve injury.
Comparisons among different studies should be
made with caution because several factors need to be
considered. One of these factors is the time at which
assessments were made. An initial assessment of nerve
damage was usually made at 1 week after surgery or
shortly thereafter. At this time, disturbed sensory func-
tion is presumed to be caused by structural changes
within the nerve, varying from demyelination (one
form of neurapraxia) to neurotmesis. Two series may
have included transient nerve injuries that were associ-
ated with trauma-related or local anestheticrelated
edema or ischemia, which generally resolve within 1
week.
44
If so, then the incidence rates for these studies
are comparatively exaggerated. The results of Mason
11
were based on sensory assessments done on the first
postoperative day; 25% of the patients recovered
within the first week. For his study, incidence rates at 1
week for the lingual split technique and the buccal
approach with a lingual retractor for his study could
not be calculated separately, because the 25% figure
refers to the two groups combined. Nevertheless,
Mason did point out that the difference in incidence
between his study and the 1983 study of Rood,
62
who
used the lingual split technique, would not have been
significant if he, like Rood, had also excluded instances
of sensory disturbances that subsided within the first
10 days. In addition, Rood
59
did not specify the exact
time when nerve function was tested. Because Mason
11
and possibly Rood
59
assessed nerve function before 1
week or less and because these studies represent 2 of
the 3 incidence rates after the lingual split technique,
the combined relative risk for temporary nerve injury
after the lingual split technique is likely to be inflated.
Rood
44
mentioned in his article that all patients
were followed up, but confirmation of recovery was
sometimes obtained by letter, but he did not quantify
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Pichler and Beirne 397
Volume 91, Number 4
Fig 1. Incidence of lingual nerve sensory disturbance after third molar removal reported according to study and surgical technique.
sometimes. Therefore, his report of no permanent
lingual nerve injuries may be somewhat unreliable with
respect to our criteria of required sensory testing.
Similarly, 2 of the 4 patients with lingual nerve injuries
were lost to follow-up after 3 months in the study of
Wofford.
58
Because these patients showed resolution
when lost from the study, they were not considered by
the author to have permanent injuries. In addition,
Mason
11
divided patients into 2 groups, in one of
which the lingual platesplitting technique was used
and in the other of which the technique was not used.
Results for the group in which the lingual split tech-
398 Pichler and Beirne ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 2001
Table I. Excluded articles
Lack of Results not separated
sensory testing in Inadequate Fewer than by cause of injury
First author reported results follow-up 10 cases or type of surgery Other
Absi
16
x
Altenmuller
17
x
Blackburn
18
x
Blackburn
19
x
Blazek
20
x x
Bruce
21
x x
Dohvoma
22
x x
Du
23
x x
Eliav
24
x
Ferdousi
25
x Combines nerves in
results
Fielding
26
x x
Goldberg
27
x
Greenwood
28
x x
Hausamen
29
x
Hillerup
30
x
Ho
31
x x x
Hochwald
32
x
Holtje
33
x x
Kummerli
34
x x
LaBanc
35
x x x x
Lopes
36
x Includes maxillary third
molar surgeries in results
Martis
37
x x Clinical exam not
defined
Mozsary
38
x
Nickel
39
x Combines nerves in
results
Osborn
40
x Combines nerves in
results
Pogrel
41
x
Reich
42
Duplicate
Robinson
43
x
Rood
44
Duplicate*
Rud
45
x x
Schmoker
46
x x x
Schmoker
47
x
Schottke
48
x
Schultze-Mosgau
49
Duplicate
Sisk
50
x
Tier
51
x x
To
8
x
van Gool
52
x
Von Arx
53
x x
Walters
54
x x
Wietholter
55
x x
Zuniga
56
x x
Zuniga
57
x x
*Duplicate of Rood
62
study population.
Duplicate of Schultze-Mosgau and Reich
61
study population.
nique was not used were complicated by some cases in
which a lingual flap was used to gain access to over-
hanging distal bone, and in some cases no bone was
removed at all.
11
The problem with comparing incidence rates among
studies, as is often done in the literature, is the variance
in study designs and study populations. Factors that are
associated with nerve damage include type of anes-
thetic, state of eruption, depth of impaction, patient
age, experience of the surgeon, and type of lingual flap
retractor.
9,21,28
These factors may have influenced the
results of our review. For example, operating surgeons
in the study of Schultz-Mosgau
61
were residents in
their first to third years, whereas for almost all other
studies the operators had varying experience (Table II).
It is possible and has been previously speculated that
nerve damage after third molar surgeries performed by
students and residents can be lower, possibly because
students/residents receive less complicated cases than
do house staff.
9
Among the exclusion criteria used to select articles in
this review was the requirement of clinical sensory
assessment tests; this was intended to decrease bias.
Techniques of sensory assessment of the trigeminal
nerve are controversial.
21,64
Much research still needs
to be done in the area of nerve damage assessment.
Sensory tests, such as light-touch and 2-point discrimi-
nation tests, appear to have the greatest objectivity.
Subjective results and results based on sensory tests
sometimes do not agree with each other. Patients can
report normal sensation when their test results are
abnormal, and vice versa.
64
Perhaps subjective reports
should be used to assess nerve injury, because it is
surely the patients opinion that matters most. However,
patient bias may influence results.
If comparisons of these studies are so difficult to make
because of variance and discrepancies, then why make
the effort? We believe that the selected studies represent
the most valid data that we could find on lingual nerve
injury after third molar surgery, and it is these studies
that should guide decision-making. If the results cannot
support the use of a lingual flap retractor for decreasing
either temporary or permanent incidences of nerve
injury during third molar surgery and instead show an
increase in temporary nerve injuries, then the decision to
use techniques involving lingual flap retraction to avoid
lingual nerve injury were not evidence-based but were
instead based on opinion and personal experience.
CONCLUSION
The studies assessed in this review represent the most
valid data available on which to base clinical decisions
with respect to lingual nerve injury resulting from use
of different methods to remove lower third molars.
This focused review of the current literature does not
show or support any significant advantage for the use
of a lingual flap retractor to protect the lingual nerve
during third molar removals; in fact, it reveals an
increased tendency toward temporary injury when a
lingual retractor is used.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Pichler and Beirne 399
Volume 91, Number 4
Table II. Variables of selected studies
Time of first When Sensory
Surgical method(s) Type of sensory considered assessment
First author Year used Surgeons anesthetic assessment permanent methods
Rood 1983 LS Several, of varying General 8-11 d 6-7 mo Clinical tests
experience
Wofford 1987 BA Several, of varying Local + sedation 1 wk 13 mo* Light-touch with
experience cotton wisp
Mason 1988 BA+ and LS N/A General 1 d 6 mo Light-touch, tactile
discrimination,
pain awareness
Obiechina 1990 BA Author Local 1 wk 6 mo Tests
Rood 1992 BA+ and LS Several, of varying General N/A 6 mo to 1 y 2-point discrimination
experience
Schultze- 1993 BA+ 5 (first- through Local 1 wk 6 mo Pointed-blunt test,
Mosgau third-year residents) pathology test
Robinson 1996 BA+ and BA Several, of varying Local and general 1 wk 3-4 mo with Sensory testing
experience no sign of
recovery
Brann 1999 BA+ Several, of varying Local and general 1 wk 6 mo Light-touch with
experience probe or cotton wool
LS, Lingual split technique; BA+, buccal approach with lingual retractor; BA, buccal approach without lingual retractor.
*Only 1 case lasted past 6 months; patient was followed to 13 months.
Established by personal communication with author.
Cases had complete anesthesia with no sign of recovery after 3-4 months; surgical exploration/repair was done at this time.
We thank Drs Jonathan Shepherd, Mark Brickley, Stefan
Schultze-Mosgau, Peter Robinson, and David Mason for
their responses to our questions regarding their studies. We
also thank Dr Linda LeResche and NIDCR, who made this
study possible; Dr Charles Spiekerman, for guidance on the
statistical analysis; Dr Alex Blaicher, for his help
obtaining articles; and Deirdre Burns, for her help and assis-
tance.
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Table III. Incidence of lingual nerve injury reported by selected studies
Incidence of Incidence of
Surgical
temporary lingual permanent lingual
method(s) First author No. of third molar
nerve injury nerve injury
used number Year procedures Number % Number %
BA+ Mason 1988 747 62 8.30 3* 0.40
Rood 1992 406 21 5.17 8 1.97
Schultze-Mosgau 1993 791 15 1.90 0 0
Robinson 1996 378 26 6.88 3 0.79
Brann 1999 718 69 9.61 5* 0.70
Total BA+ 3040 193 6.35 19 0.63
BA Wofford 1987 576 4 0.70 1 0.17
Robinson 1996 393 3 0.70 1 0.25
Obiechina 1990 367 1 0.27 0 0
Total BA 1336 8 0.60 2 0.15
LS Rood 1983 1400 93 6.64 0 0
Mason 1988 293 58 19.80 3* 1.02
Rood 1992 384 49 12.76 0 0
Total LS 2077 200 9.63 3 0.14
LS, Lingual split technique; BA+, buccal approach with lingual retractor; BA, buccal approach without lingual retractor.
*Confirmed by personal communication with author.
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Reprint requests:
Jennifer Renae Withrow Pichler, BS
c/o O. Ross Beirne, DMD, PhD
University of Washington
Department of Oral and Maxillofacial Surgery
Box 357134
Health Sciences Building B-241
Seattle, WA 98195
jennibee@u.washington.edu
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Pichler and Beirne 401
Volume 91, Number 4