255

BRI TI SH JOURNAL OF ORAL & MAXI LLOFACI AL SURGERY

British Journal of Oral and Maxillofacial Surgery (2000) 38, 255263
2000 The British Association of Oral and Maxillofacial Surgeons
doi:1054/bjom.2000.0463
INTRODUCTION
Damage to the lingual nerve during removal of lower
third molars remains an important clinical problem.
The reported incidence of this complication varies
widely from 0.2%
1
22%,
2
partly depending on the
surgical technique used. In the UK, the traditional
method of raising both buccal and lingual flaps and
inserting a Howarths periosteal elevator to displace
and protect the nerve results in a high incidence of
temporary damage,
25
and we have recently shown
that this technique is invalid.
6
However, most of these
sensory disturbances resolve over the course of a few
weeks or months, leaving a small group of about
0.5%
36
with permanent sensory disturbance. In this
group, the symptoms vary widely from a minor degree
of hypoaesthesia to severe dysaesthesia, and many
patients complain bitterly about problems with
speech, mastication, and taste. It seems that such
patients will present intermittently whichever surgical
technique is used for third molar removal, and
because the operation is so common it is an important
clinical and medicolegal problem. It is the manage-
ment of this group of patients that is the subject of
this paper.
The use of microsurgical techniques to repair dam-
aged lingual nerves was first described about 20 years
ago, but reports included little information about
outcome,
79
or about the methods used to assess a
successful result.
10
The first published reports on
outcome evaluated by sensory testing appeared in the
1990s
1116
and, while some results were encouraging,
the number of patients assessed was small or
they were treated by a range of different surgical
techniques. The largest report was from a retrospec-
tive postal questionnaire appraisal of 205 lingual
nerve repairs at seven units in the USA.
17
The opera-
tions included decompression, direct suture, or graft-
ing, and although the authors reported an 80%
success rate their primary conclusion was it is appar-
ent that there is need for a detailed prospective study
of specific injury conditions and their response to
standardised microneurosurgical interventions. A
recent critical appraisal of publications confirms this
view.
18
Our approach to the management of patients with
persistent lingual sensory disturbance is the result of
an extensive series of animal investigations. Using a
combination of electrophysiological and ultrastruc-
tural techniques, we have assessed the extent of func-
tional recovery of each of the nerve fibre groups in the
lingual branch of the trigeminal nerve and the chorda
tympani after a range of manipulations and recovery
periods. These studies allowed assessment of the
functional characteristics of mechanosensitive,
thermosensitive, and gustatory fibres which have
regenerated after injury, as well as quantification of
the recovery of the autonomic fibres responsible for
salivary secretion and vasomotor effects. These data
showed that permanent sensory abnormalities are
more likely to result from nerve section than from a
crush injury;
1921
that repair by epineurial suture is
more effective than entubulation,
2224
that repair of a
gap is better achieved by mobilization of the stumps,
than by sural nerve grafts or autologous frozen skele-
tal muscle grafts;
25,26
and that a three-month delay
before repair has little effect on the outcome.
27,28
Attempts to improve recovery by the application of
A prospective, quantitative study on the clinical outcome of lingual nerve
repair
P. P. Robinson, A. R. Loescher,* K. G. Smith
Professor of Oral & Maxillofacial Surgery; *Senior Lecturer in Oral & Maxillofacial Surgery; Senior
Lecturer in Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, University of
Sheffield, UK
SUMMARY. We previously showed in laboratory studies that the most effective method for repair of damaged
lingual nerves was by excision of the neuroma, mobilization of the stumps, and direct reapposition with epineurial
sutures. We have now undertaken a prospective study in a series of 53 patients treated by this method and have
evaluated the outcome by quantifying and comparing the results of tests of sensation before and after operation. The
outcome in individual patients was variable. However, pooled data from all patients showed a highly significant
improvement in sensation at the final assessment 12 months or more after the repair. The proportion of patients who
responded to most or all light touch stimuli increased from 0% to 51% after repair, and the proportion who responded
to pin-prick stimuli increased from 34% to 77%. There was no correlation between the final results of any of the tests
and the delay before repair. None of the patients regained completely normal sensation and there was no reduction in
the number with spontaneous paraesthesia or pain. However, fewer patients tended to bite the tongue by accident and
most of them considered the operation worthwhile. These data show that lingual nerve repair is effective in most
patients and we suggest that it should be offered to all those who show few signs of spontaneous recovery after injury.
neurotrophic agents to the repair site were unsuccess-
ful.
29
We have taken the principles derived from all of
these studies and have now applied them to the man-
agement of a series of patients.
Our clinical study has been prospective, and the
results of a series of sensory tests done before and
after operation have been quantified to allow statisti-
cal comparisons. To our knowledge, this is the largest
single-centre study on the outcome of lingual nerve
repair in the world literature, and we have specifically
addressed the following questions:
Is it worthwhile?
Do some sensory functions recover better than
others?
Does nerve repair reduce dysaesthesia?
Is early repair more effective than late repair?
PATIENTS AND METHODS
The series comprised 53 of the patients referred to our
nerve injury clinic in Sheffield. All the injuries had
occurred during removal of third molars and the
patients had been selected as appropriate for opera-
tion because they showed little or no evidence of
recovery by three months after the injury
27,28,30
or very
limited recovery at later stages. This series represents
88% of the patients who had this type of surgery dur-
ing the study period of about eight years (19901998);
we excluded an additional seven patients because they
failed to attend for review and evaluation. There were
15 men and 38 women, mean age 30 years (range
1654), and the injuries were on the left side in 30
patients and on the right side in 23. The delay before
nerve repair ranged from 4 to 47 (mean 15) months.
All the repairs were done under general anaesthesia
by one of the three authors and the technique was
similar for each patient. An incision was made down
the external oblique ridge to the distobuccal gingival
margin of the second molar and around the lingual
aspect of the teeth as far as the second premolar,
where a small relieving incision was made into the
floor of the mouth. The lingual flap was raised, taking
great care not to tear the tissues at the site of scarring
from the previous operation, and the floor of the
mouth was lifted by a retraction suture placed though
the distal mucosa and attached to the maxillary
tuberosity. A notch or perforation through the lingual
aspect of the alveolus often indicated the site of nerve
damage, and presumably indicated the point at which
bone removal had been allowed to extend (inappropri-
ately) through the lingual plate.
The lingual periosteum was carefully divided to
gain access to the nerve, which was always trapped in
dense scar tissue and sometimes expanded to form a
neuroma (Fig. 1A). In about half the patients, there
was evidence of some degree of continuity between
the proximal and distal stumps of the nerve but in the
others the nerve seemed to have been completely
divided, and the two ends had retracted apart. Small
fragments of metal were sometimes found embedded
within the epineurium and scar tissue, and these
had presumably been shaved from the edge of the
Howarths elevator by the bur during the initial opera-
tion. After dissecting the proximal and distal stumps
free and assessing their extensibility, the segment of
nerve that looked damaged under the operating
microscope was excised. This excised segment was
414 (mean 9.5) mm in length and, where possible,
included all the expanded neuroma. As we did not
graft the nerves, the length of excised segment was
restricted by the extensibility of the two nerve stumps
and this may have been restricted by intraneural fibro-
sis after the more severe injuries. Repair was by 510
(mean 7) epineurial sutures (Fig. 1B) with 8/0
monofilament polyamide (Ethilon, Ethicon Ltd,
UK). The wound was closed with polyglactin 910
(Vicryl) and all patients were given prophylactic
antibiotics and dexamethasone (8 mg preoperatively
and 12 h postoperatively).
In all patients, sensation on the affected side of the
tongue was assessed preoperatively and at approxi-
mately 1, 4, and 12 months or more (median 13
months) postoperatively. Initially each patient was
asked a series of standard questions from a proforma:
whether the affected part of the tongue was com-
pletely numb; whether it was painful; whether they
had tingling (paraesthesia) spontaneously or initiated
256 British Journal of Oral and Maxillofacial Surgery
Fig. 1 (A) A large neuroma on the lingual nerve (arrows) at the
site of damage during the removal of an impacted third molar 18
months earlier. (B) The neuroma has been excised and the nerve
ends mobilized and repaired using epineurial sutures (arrow).
B
A
by touching or moving the tongue; whether they
tended to bite the tongue by accident; and whether
they thought that their speech or taste was affected.
We then made an examination to establish the pres-
ence of fungiform papillae on each side of the tongue,
the presence of a palpable neuroma in the third molar
region, or sensation in the tongue evoked by palpation
in this region. A series of sensory tests
31
was then
done by one of the authors (PPR or KGS) in a quiet
room with the patients eyes closed and the tongue
protruded.
Light touch sensation
A von Frey hair, which applied a force of 20 mN (2 g),
was applied at random to both sides of the tongue
and the patients asked whether they could feel it. Any
area of anaesthesia was mapped by applying the stim-
ulus within the area and then moving it outwards in
small steps until a sensation was felt. For quantitative
comparisons, responses were graded on a four point
scale: 0, no response; 1, response at the tip only; 2,
response in most areas; 4, responses apparently simi-
lar to those on the unaffected side.
Pin-prick (pain) sensation
Forces of up to 150 mN (15 g) were applied randomly
to both sides of the tongue with a pin attached to a
calibrated spring, and the patients were again asked to
indicate whether or not they felt anything. Areas of
anaesthesia were mapped. In addition, within areas
from which a sensation could be evoked, the pin-prick
sensation threshold was measured by asking the
patients to indicate the point at which a pin applied
with steadily increasing pressure became sharp rather
than dull. This test was repeated at a number of sites.
Responses were quantified as: 0, no response; 1,
response at the tip only; 2, response in most areas but
with an increased threshold; 4, responses apparently
similar to those on the unaffected side.
Two-point discrimination
This test was done with an instrument comprising 10
pairs of blunt probes (each 0.8 mm in diameter) with
separations ranging from 2 to 20 mm at 2 mm inter-
vals.
31
The probes were drawn 510 mm across the sur-
face of the tongue, approximately 12 cm from the tip,
and the minimum separation which was consistently
reported as two points was recorded as the two-point
discrimination threshold.
Taste sensation
Cotton wool pledgets soaked in 1 M sodium chloride,
1 M sucrose, 0.4 M acetic acid, or 0.1 M quinine were
drawn 12 cm across the lateral border of the tongue
and the patients asked to indicate whether they tasted
salt, sweet, sour, bitter, or had no taste, before replacing
the tongue in the mouth. Eight tests (two of each stim-
ulus) were applied in random order to each side of the
tongue, and rinsing with tap water between tests was
permitted. Responses were simply quantified as: 0, no
response; 1, some correct responses; 2, a similar num-
ber of correct responses on each side of the tongue.
Electrogustometry
Monopolar constant-current electrical stimuli of up
to 7 mA were applied to an area about 1 cm from the
tip and 1 cm from the midline of the tongue, with a
flat stainless steel electrode (diameter 5 mm). The
patient was asked to indicate the point at which a
tingle or metallic taste was detected, and the thresh-
old of this sensation was recorded on two occasions
on each side of the tongue. The mean value of these
two tests was used for statistical comparisons.
Finally, at the last testing session only, the patients
were asked to give a subjective score to the value of
the operation on a scale of 0 to 10. They were told
that 0 indicated that the operation had been a waste of
time, and that 10 indicated a perfect outcome. They
were told to consider this only from their own
perspective, ignoring the results of the sensory testing
and the feelings of the operators.
Statistical comparisons between the results of tests
at different stages were made with the
2
test or Mann-
Whitney U test as appropriate, unless otherwise
stated. The effect on outcome of delay between injury
and repair was assessed with Pearsons correlation
coefficient.
RESULTS
Responses to questions
A comparison between the responses to questions
asked preoperatively and at the final test is shown in
Table 1. There was a highly significant reduction in
the number of patients who thought that the affected
part of the tongue was completely numb (34 to 6,
P<0.001). A substantial proportion of the patients
(n=16) initially reported pain from the affected part of
the tongue and almost half of them (n=25) had spon-
taneous paraesthesia. There was no significant change
in the number reporting these problems at the final
assessment and, although some patients reported a
reduction in the intensity of these symptoms, we did
not attempt to quantify this difference. There was a
small but insignificant increase in the number of
patients who reported paraesthesia initiated by touch-
ing or moving the tongue, suggesting abnormal prop-
erties of the reinnervated receptors on the tongue.
Accidental tongue biting was initially a problem for
39 patients but there was a significant reduction in this
number at the final assessment (n=26, P<0.02). A
large proportion of patients reported disturbances of
speech (n=30) and taste (n=34) and these proportions
had not changed significantly at the final assessment.
Clinical outcome of lingual nerve repair 257
Observations
There appeared to be fewer fungiform papillae on the
affected side of the tongue in 34 (74%) of the patients
preoperatively, and in 24 (45%) at the final assessment
(P<0.01). An expanded swelling, thought to be a neu-
roma, could be detected by palpation in five preopera-
tively, and in four after operation (P=1). Palpation in
the lingual sulcus at the site where the nerve injury
would have been expected, evoked a sensation in the
tongue in 31 patients (58%) before operation, and in
29 (55%) after operation.
Sensory tests
On the normal (control) side of the tongue, the
patients were all able to detect light touch stimuli with
a 20 mN von Frey hair, pin-prick stimuli of up to
150 mN, and the electrical stimuli. The two-point dis-
crimination thresholds ranged from 2 to 10 mm
(median 4), and the ability to identify correctly the
gustatory stimuli ranged from 1 to 8 (median 6) out of
eight trials.
The results of the sensory tests on the side of injury
are shown graphically in two ways. Firstly, for the
responses to light touch and pin-prick stimuli, the
number of patients who responded in some way to
these stimuli at each assessment interval is shown in
Figure 2. In each case, these charts show a reduction
in the number of patients who responded in the early
postoperative period, followed by a progressive
increase beyond the initial numbers, until 42 (79%)
and 47 (89%), respectively, responded at the final test.
A more critical appraisal of the outcome is shown by
comparing the quantitative scores recorded at the pre-
operative and final postoperative assessments. These
data are shown for the responses to light touch stimuli
in Figure 3 and show that 27 (51%) of the patients
responded to tests in most or all areas at the final
assessment, with a highly significant improvement in
the pooled responses (P<0.0001). Equivalent data for
the responses to pin-prick stimuli are shown in Figure
4; 41 of the patients (77%) responded to tests in
most or all areas at the final test, again with a highly
significant improvement in the pooled responses
(P<0.0001). Because of the size of the tongue, two
point discrimination thresholds could be recorded for
each side only if they were less than 16 mm, and the
results are shown in Figure 5. The pooled data again
show a highly significant reduction in thresholds
(P<0.0001). Figure 6 indicates the extent of recovery
of gustatory responses: 11 patients (21%) could
detect some taste solutions preoperatively, and 33
(62%) postoperatively (P<0.0001). Electrogustometry
evoked responses from 13 patients preoperatively,
with a mean (SEM) threshold of 497 (31) A.
Postoperatively responses were evoked in 42 patients
(P<0.0001) with a mean (SEM) threshold of
312 (27) A (P<0.001, Students t test).
258 British Journal of Oral and Maxillofacial Surgery
Table 1 Response to questions (Data are number (%) of patients (n=53))
Preoperatively Postoperatively P value
Complete numbness? 34 (64%) 6 (11%) <0.0001
Pain? 16 (30%) 14 (26%) 0.8
Spontaneous tingling? 25 (47%) 24 (45%) 1
Touch-evoked tingling? 9 (17%) 15 (28%) 0.3
Movement-evoked tingling? 10 (19%) 17 (32%) 0.2
Tongue biting? 39 (74%) 26 (49%) <0.02
Speech affected? 30 (57%) 30 (57%) 1
Taste disturbance? 34 (64%) 30 (57%) 0.6
B A
Fig. 2 (A) The number of patients who could detect some light touch stimuli with a 20 mN von Frey hair on the affected side, at various
stages before and after operation. (B) The number of patients who could detect some pin-prick stimuli of up to 150 mN on the affected
side, at various stages before and after operation.
Clinical outcome of lingual nerve repair 259
Fig. 3 (A) The level of responses to light touch stimuli with a 20 mN von Frey hair preoperatively, subdivided on a four point scale as
described in the text. (B) The level of responses to light touch stimuli at the final postoperative test, subdivided on a four point scale. The
difference between the preoperative and postoperative data is highly significant (P<0.0001).
Fig. 4 (A) The level of responses to pin-prick stimuli of up to 150 mN preoperatively, subdivided on a four point scale as described in the
text. (B) The level of responses to pin-prick stimuli at the final postoperative test, subdivided on a four point scale. The difference between
the preoperative and postoperative data is highly significant (P<0.0001).
A B
A B
Fig. 5 (A) The two point discrimination thresholds measured preoperatively. Because of tongue size, a threshold of more than 14 mm
could not be reliably assessed and these patients have been placed in the >16 mm column. (B) The two point discrimination thresholds
assessed at the final postoperative test. The difference between the preoperative and postoperative data is highly significant (P<0.0001).
A B
Subjective assessment
The patients subjective assessment of the value of the
operation, taking all aspects into account, is shown in
Figure 7. The scores covered the full range from 0 to
10, four patients giving a score of 0 and 42 giving a
score of 5 or more. The median score was 7.
Effect of delay in repair
The relation between the final outcome of operation
and the period between injury and repair was assessed
for all sensory tests and the patients subjective scores.
In no case was there any significant correlation and an
example is shown in Figure 8. This figure shows the
difference between two point discrimination thresh-
olds on each side of the tongue at the final test, as a
good indicator of the level of recovery, plotted against
the delay in repair.
DISCUSSION
This discussion will be structured to consider the four
questions posed in the introduction.
Is lingual nerve repair worthwhile?
The extent of sensory recovery after our method of
lingual nerve repair was variable, but the overall
results were good. There were highly significant
improvements in the pooled responses to light touch,
pin-prick, and gustatory stimuli (including electrogus-
tometry), and highly significant reductions in the two
point discrimination thresholds. The proportion of
patients who responded to most or all light touch
stimuli increased from 0% to 51% after the repair and
the proportion who responded to most or all pin-
prick stimuli increased from 34% to 77%. This
improved level of sensation resulted in a significant
reduction in the number of patients who reported
accidental tongue biting, although persistent speech
and taste disturbances were reported in 57% and 64%
of the patients, respectively. Most patients considered
the operation worthwhile with a median subjective
score of 7 on a scale of 010, and this equates closely
with the mean score of about 2.5 on a scale of 04
reported for global satisfaction, by Zuniga et al.
16
260 British Journal of Oral and Maxillofacial Surgery
Fig. 6 (A) The level of responses to gustatory stimuli preoperatively, subdivided on a three point scale as described in the text. (B) The
level of responses to gustatory stimuli at the final postoperative test, subdivided on a three point scale. The difference between the
preoperative and postoperative data is highly significant (P<0.0001).
A
B
Fig. 7 The overall value of the operation as assessed subjectively
by the patients on a scale of 010 (n=51).
Fig. 8 The delay (months) between the nerve injury and repair
plotted against the final outcome expressed as the difference
between the two point discrimination thresholds on the affected
and unaffected sides of the tongue (P>0.2).
Comparisons between our results of sensory tests
and those reported in other studies is difficult because
of variations in methods, but there are some similari-
ties. Riediger et al.
11
indicated good or excellent recov-
ery (with recovery of protective sensitivity) in 44% of
16 patients who had repair by direct suture. LaBanc
and Greggs retrospective multicentre study
17
reported
that 80% of patients could detect light touch stimuli
from a von Frey hair or camel-hair brush more than
80% of the time, but this type of study poses
particular difficulties in observer consistency. Finally,
Hillerup et al.
13
found that, after repair, five of six
patients could detect light touch stimuli, and all six
could detect pin-prick stimuli, but the responses were
always subnormal.
To summarize the data from the present and previ-
ous studies, it seems clear that lingual nerve repair
is a worthwhile procedure for most patients. This
favourable outcome was predicted by our preliminary
animal work.
Do some sensory functions recover better than others?
Our patients gave little indication of different levels of
recovery for different sensory functions. Experiments
in laboratory animals have suggested this possibility,
as large diameter nerve fibres seem to regenerate more
successfully than small diameter fibres
32
and specific
functional groups are associated with a particular
range of fibre sizes. This may explain the poor recov-
ery of the small diameter gustatory fibres in our
laboratory experiments,
19,23
although it could also
have occurred because few of this small population
would be likely to encounter an appropriate
endoneurial sheath in the distal nerve stump, and be
guided to a suitable taste-bud receptor site. In view of
this, we were slightly surprised to find the presence of
some responses to gustatory stimuli in 62% of our
patients after repair. This contrasts with the results of
Riediger et al.
11
who found recovery of taste sensation
in only one of their patients, but is consistent with the
reports of Hillerup et al.
13
and Zuniga et al.,
33
who
reported some recovery of taste. The later report of
Zuniga et al.
16
recorded return of gustatory responses
in five of 10 patients, which is similar to our results.
The reduction in the number of patients who had
fewer fungiform papillae on the side of injury after
repair is a physical expression of the reinnervation by
gustatory fibres, and has been reported previously.
14,33
A higher proportion of our patients responded to
pin-prick (painful) stimuli, than light touch stimuli. It is
unlikely that this indicates better regeneration of noci-
ceptive fibres than low-threshold mechanoreceptive
fibres, and probably merely reflects the higher intensity
of the pin-prick stimuli. Previous laboratory investiga-
tions have shown that, even after long recovery periods,
reinnervated mechanoreceptors have reduced levels of
sensitivity
34
and may, therefore, respond only to higher
intensity stimuli. On the tongue, the reinnervated recep-
tors may fail to respond to a 20 mN von Frey hair, as
used in this clinical study.
20
A number of other changes in the characteristics of
regenerated nerve fibres have been reported in studies
on both trigeminal and other peripheral nerves.
35
These include alterations in the number and diameter
of myelinated and non-myelinated axons in the proxi-
mal and distal nerve stumps,
21,35
changes in conduc-
tion velocities, and alterations in mechanoreceptive
fields.
19,20,35,36
In view of these changes, it is not surpris-
ing that patients do not regain normal sensation after
reinnervation of the tongue, and continue to report
some abnormalities. LaBanc and Gregg
17
noted that,
despite evidence of recovery, some patients still com-
plained of numbness, and in our study no patient
reported completely normal sensation after repair.
Does nerve repair reduce dysaesthesia?
In our study, nerve repair resulted in no significant
change in the number of patients who reported pain
or spontaneous paraesthesia. We were surprised by
this, as we had the impression that the symptoms
of dysaesthesia were reduced by the operation.
Unfortunately, our assessment protocol did not
include any quantification of the extent of symptoms,
but other studies have clearly indicated a reduction.
Gregg
37
reported a 49% reduction in severity of pain
in 31 patients after lingual nerve repair, and indicated
that the results seemed to vary according to the nature
of the sensory disorder. The retrospective multicentre
study by LaBanc and Gregg
17
suggested that repair
resulted in a 30% reduction in pain levels in 67.5% of
patients with hyperaesthesia, and Pogrel and Kaban
38
reported uniformly excellent results as far as elimina-
tion of dysaesthesia was concerned.
It has been our experience that the treatment of
dysaesthesia after lingual nerve injury remains one of
our most difficult problems. Pain was reported by 30%
of our patients, and spontaneous paraesthesia by 47%,
and the low incidence of lingual dysaesthesia reported
in one recent study is surprising.
39
The aetiology of this
complex group of sensory disorders remains uncer-
tain
40
but our recent animal studies have shown the
development of persistent spontaneous neural activity
from a nerve injury site,
4143
together with the accumu-
lation of a range of neuropeptides.
44
These two obser-
vations seem linked, as they have a similar temporal
relationship, and this raises the possibility of new
pharmacological approaches to treatment. The labora-
tory studies have also shown the development of
mechanical sensitivity of the damaged axons.
4143
This
is consistent with the observation that palpation over
the site of nerve injury evoked a sensation in the
tongue in 58% of our patients. As this could still be
evoked in 54% of our patients after repair, it suggests
that there are still many mechanosensitive axonal
sprouts trapped in scar tissue in this region.
Is early repair more effective than late repair?
Several previous papers have suggested that late
repair is followed by a poorer outcome than early
Clinical outcome of lingual nerve repair 261
repair
10,38
and Riediger et al.
11
were sceptical about
repair undertaken more than 12 months after the
injury. Meyer
45
reported 90% success if the repair was
undertaken within three months, reducing to 10%
success by 12 months, although the nature of his
analysis is unclear. These papers are at odds with the
results in our large series of patients, in whom there
was no significant correlation between delay and any
measure of outcome. Hillerup et al.
13
in their small
series, also reported no significant correlation. The
results of animal studies are variable but generally
agree that early repair and regeneration should be
more effective, in that both central and peripheral
degenerative changes should be limited.
27,28
How can
this discrepancy be reconciled? A likely explanation is
that, for an individual patient, early repair has the
potential to produce the optimal result but, when a
large population is studied, other factors are domi-
nant and mask this effect. The dominant factor is
probably the extent of nerve injury caused by the
initial operation. As most injuries in our series were
likely to have been caused by the surgical bur, damage
could have varied from partial nerve section through
to complete division, and may have been complicated
by extensive stretching of the nerve stumps, leading
to intraneural fibrosis along a substantial section of
nerve. Such factors are likely to be responsible for the
variable outcome of repair. Nevertheless, our present
and previous
14
results clearly show that late repair can
result in improvement and is considered by most
patients to be worthwhile.
CONCLUSIONS
We conclude that the method we have described for
early or late lingual nerve repair is effective. Most
patients regain some sensation, fewer bite the tongue
by accident, there are highly significant improvements
in the results of sensory tests, and the patients con-
sider it worthwhile. The results of direct reapposition
by epineurial suture seem to be better than those
reported after other methods of repair such as nerve
grafting,
11,15,38
artificial conduits,
46
or external neuro-
lysis.
12
Nevertheless, the outcome of operation is still
not ideal as some patients do not improve, speech and
taste sensation may remain affected, and recovery is
never complete. While there may be technical
advances, such as the accurate location and assess-
ment of the injury using magnetic resonance imag-
ing,
47
improvements in outcome are likely to result
from improving the potential for regeneration. This
might be achieved, for example, by the incorporation
of neurotrophic agents at the repair site.
29
Other
advances are needed to improve the management of
patients with dysaesthesia.
37
Acknowledgements
We thank colleagues who referred patients to our unit for
management, and the patients who attended regularly to undergo
our assessment protocol.
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The Authors
P. P. Robinson BDS, PhD, DSc, FDSRCS
Professor of Oral & Maxillofacial Surgery
A. R. Loescher BDS, MBChB, PhD, FDSRCS
Senior Lecturer in Oral & Maxillofacial Surgery
K. G. Smith BDS, PhD, FDSRCS
Senior Lecturer in Oral & Maxillofacial Surgery
Department of Oral & Maxillofacial Surgery
University of Sheffield
Sheffield, UK
Correspondence and requests for offprints to: Professor P. P.
Robinson, Department of Oral & Maxillofacial Surgery, School of
Clinical Dentistry, Claremont Crescent, Sheffield S10 2TA, UK
Paper received 2 November 1999
Accepted 23 May 2000
Clinical outcome of lingual nerve repair 263