You are on page 1of 3

British Journal of Oral and Maxillofacial Surgery (1999) 37, 134–136

© 1999 The British Association of Oral and Maxillofacial Surgeons

BRITISH JOURNAL OF ORAL

& M A X I L L O FA C I A L S U R G E RY

Sensory disorders after separation of the nasopalatine nerve during removal
of palatal displaced canines: prospective investigation
A. Filippi, Y. Pohl, U. Tekin
Department of Oral Surgery, University of Gieβen, Germany
SUMMARY. During a prospective study after separation of the nasopalatine nerve at the foramen incisivum during
exposure or removal of impacted and palatal displaced maxillary canines, 59 patients were examined neurologically
for 4 weeks postoperatively over an investigation period of 18 months. During the first week after the operation,
subjective as well as objective sensory disorders were found in all of the patients, but after 4 weeks at the most no
neurological deficit could be detected in any patient.

INTRODUCTION
Apart from the third molars, the maxillary canines are
most often prevented from assuming their correct
alignment in the row of teeth. The prime cause of this
is lack of space, because maxillary canines erupt after
the adjacent teeth. Depending on age and the particular orthodontic state, the methods of treatment can
entail exposure and orthodontic alignment, autologous tooth transposition1 or removal by osteotomy.
As most of the maxillary canines are displaced
palatally,2,4 they must be approached from that direction. When only the displaced tooth is exposed and a
ligature is used, and provided that the displaced tooth
is both palpable and visible, excision of the oral
mucosa around the crown of the canine tooth5 or an
incision to obtain a roll flap6,7 are indicated. However,
if it cannot be palpated, and in all tooth extractions
requiring osteotomy, a more generous incision must
be made to ensure good general viewing during the
operation.
Different types of incision are recommended for
removal of teeth from the palate (Fig. 1). One possible
way to classify these is to differentiate between paramarginal types of incision3,8–10 and incisions of the gingival margin.11–13 Another way is to divide the types of
incisions into those that are as gentle as possible to the
vascular nerve bundle at the foramen incisivum either
by cutting round it or by avoiding it4,14–16 and those that
sever these structures.10,11,17 The present investigation
will shed some light on the incidence of postoperative
sensory alterations in the mucous membrane of the
mouth in the region of the anterior teeth after the
nasopalatine nerve has been severed peroperatively.

Fig. 1 – Diagram of palatal types of incision for the surgical
removal of the impacted and displaced tooth 13. 1 = incision of
the gingival margin, 2 = paramarginal incision, 3 = paramarginal
incision with a median-relieving incision, avoiding the foramen
incisivum.

removing the tooth, the mucoperiosteal flap is
replaced and fixed by interdental sutures. A prepared
oral guard is then inserted and kept in by the patient
for about a week until the stitches can be removed.
During the investigation period of 18 months (July
1995–December 1996) the vascular nerve bundle in
the region of the foramen incisivum was severed with
a scalpel in the course of removal or exposure of
canines in 59 patients. After the operation they were
invited to attend follow-up examinations scheduled
after 24 h and 1, 2 and 4 weeks. The following variables were recorded: patient’s age at the time of the
operation, time since the operation, subjective presence of adverse sensations, and objective findings of
sensory disorders in the nerve supply to the nasopalatine nerve by using the ‘pointed/blunt discrimination’

PATIENTS AND METHODS
We treat impacted or displaced teeth, which are clinically neither visible nor palpable, by cleanly severing
the vascular nerve bundle at the foramen incisivum
after incising the palate at the gingival margin. After
134

8.12. Zur Einreihung des palatinal impaktierten Eckzahnes: Methodik und Ergebnisse eines kombinierten kieferchirurgischen/kieferorthopädischen Vorgehens. 6. Die Behandlung retinierter Front. At the time of the operation the patients’ mean (SD) age was 23 (15) years (range 9–48. Boyd RL. and removal of the tooth under good viewing conditions is not guaranteed. eds.18 Neurological deficiencies of the nasopalatine 135 nerve were evident in only a few isolated elderly patients. The surgical uncovering and orthodontic positioning of unerupted maxillary canines. Damage of adjacent periodontia during removal of the bone is then less likely. Kirschner H. Joho JP. Schatz JP. only a slight feeling of swelling was noticed. Spezielle Chirurgie. München: Hanser. There is no bleeding worth mentioning from the severed periodontal vessels at the foramen incisivum. RESULTS In the patients examined after the operation. Am J Orthod 1975. Schwarz M. 12. 82: 478–486. Sensibilitätsstörungen nach chirurgischer Durchtrennung des Nervus nasopalatinus bei operativer Eckzahnentfernung. Reichart PA. After 2 weeks. an incision of the gingival margin or a modified variation which is gentle to the papilla. 5. Impairment of the patients by neurological deficiencies. Eine neue Methode der operativen Freilegung retinierter Zähne. Dtsch Zahnärztl Z 1983. München: Hanser. There was no sensation of numbness in the tips of the papillae or in the mucous membrane of the palate dorsally from the first plica palatina transversa. Eskici A. ed. Zahnentfernung. Berten JL. Any concerns about postoperative neurological deficiencies have already been investigated by us.und Gesichtschirurgie. 68: 256–276. Schramm-Scherer B. . Von der Heydt K. At the follow-up examination 1 week postoperatively all patients had objective sensory disorders. München: Urban & Schwarzenberg. 15. over the last few years.11. Droschl H. Zahnextraktion und ihre Komplikationen. which may occur. 4.3 offers better viewing and so should be used. Krüger E. is minor and should not be compared with anaesthesia in the region supplying the nervus mentalis or the nervus palatinus major. 94: 33–36. The type of incision recommended for the best possible intraoperative view. Strobl H. Ergebnisse nach chirurgischer Freilegung und kieferorthopädischer Einordnung von Eckzähnen. Stuttgart: Thieme. Byloff F. Berlin: Quintessenz. 7: 45–54. 14. primarily the lateral incisor. Grimm G. References 1. Usually there is contact between the crown of the canine and the root of a functioning adjacent tooth. Die ambulante Chirurgie des Zahnarztes. Rybczynski S.Sensory disorders following separation of the nasopalatine nerve method (neurological test using a pointed and a blunt instrument) and comparing each time with the palatal mucous membrane in the region of the lateral teeth. Berlin: Quintessenz. Fortschr Kiefer Gesichts Chir 1995. the crown of the tooth that has to be removed is in these cases completely or partly covered by retained mucous membrane. München: Urban & Schwarzenberg. 9. Clinical assessment of injuries in orthodontic movement of impacted teeth. Steinhäuser EW. 1995: 32–33. Zahnärztliche Operationslehre. 1988: 258–261. 40: 100–103. These anaesthetic feelings have been classified as ‘insignificant’ in all the cases. Operationslehre für Zahnärzte. 26: 830–831. Janson IM. Bernard JP. 38: 161–170. Int J Adult Orthodont Orthognath Surg 1992. Die operative Freilegung retinierter und verlagerter Zähne der zweiten Dentition. so that reduced regenerative ability has to be assumed in these cases. Klinik und Therapie retinierter Zähne. Dtsch Zahnärztl Z 1987. Aderholt L. Raetzke P. is therefore the one best suited to the incision of gingival margin with severance of the vascular nerve bundle at the foramen incisivum. Tetsch P. Geiger G. eds. 1989: 184–186. median 16). 42: 171–173. Meyer W. Filippi A. 31 patients still had objective sensory disorders. Mund-. 38: 532–537. 1990: 37–40. Kiefer. 18. Dtsch Zahnärztl Z 1971. 13. Leilich G. Dtsch Zahnärztl Z 1993. In: Hausamen JE. In: Horch HH. Kieferorthopädische Chirurgie. in the case of crowding between a displaced tooth and the roots of teeth that are properly positioned. Berlin: Springer. 3. In: Schwenzer N. With a paramarginal type of incision or cutting around the papilla incisiva. 1996: 101–111. Dentoalveoläre Chirurgie. In this prospective study no subjective or objective sensory disorders were found more than 4 weeks after operation in any of the patients. Manhartsberger C.und Eckzähne – eine gemeinsame Aufgabe für Kieferchirurgen und Kieferorthopäden. The area of the anaesthetized zones extended from the ventral plica palatina transversa into the interdental papillae of the anterior teeth. Filippi A. Seven patients did not notice any sensory changes. 7. tooth 13 was treated by severing the nasopalatine nerve in 26 cases and tooth 23 in 33 cases. Beckers H. Fortschr Kieferorthop 1977. Zahnärztliche Chirurgie. It has therefore been recommended that. retrospectively. particulary during complicated surgical removal of palatal impacted and displaced teeth (possibly as a result of ankylosis or root anomaly). Z Stomatol 1997. Schmelzeisen R. Zur operativen Freilegung und orthodontischen Einordnung retinierter und verlagerter Eckzähne. 1989: 145–149. Twenty-five of the patients were male and 34 female.17 Potential contacts between the canine and the roots of properly positioned teeth can be recognized by direct viewing. In: Frenkel G. Neufang HJ. Severely impacted canines: autotransplantation as an alternative. Müller W. 2. 1982: 131–133. By 4 weeks no subjective or objective sensory disorders were diagnosed in any of the patients. or both. Am J Orthod 1982. Reuther J. 17. The greatest disadvantage of these types of incisions is the general lack of visibility within the operating area. Machtens E. 1961: 36–38. eds. Pilarz GF. Tränkmann J. Atlas der chirurgischen Zahnerhaltung. 10. 11. Frenkel G. 16. The subjective sensory disorders recorded at the same time indicated alterations in keeping with a slight swelling in 52 of the cases. Neurological symptoms such as sensory disorders have been observed in only isolated cases. DISCUSSION Some types of incisions were favoured to avoid potential sensory disorders of the nasopalatine nerve by cutting around the papilla incisiva or avoiding it. 48: 540–542.

Abteilung Oralchirurgie und Zahnärztliche Poliklinik. Medizinisches Zentrum für Zahn-. Tekin DDS Department of Oral Surgery University of Gieβen Germany Correspondence and requests for offprints to: Dr Andreas Filippi.und Kieferheilkunde.136 British Journal of Oral and Maxillofacial Surgery The Authors A. Germany Paper received 30 April 1997 Accepted 16 June 1997 . Filippi DDS Y. D-35392 Gieβen. Pohl DDS U. Mund. Schlangenzahl 14.