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TECHNICAL STRATEGY
Microsurgical Decompression of Inferior Alveolar Nerve
After Endodontic Treatment Complications
Bernardo Bianchi, MD, Andrea Ferri, MD, Andrea Varazzani, MD,
Michela Bergonzani, MD, and Enrico Sesenna, MD
Abstract: Iatrogenic injury in oral surgery is the most frequent
cause of sensory disturbance in the distribution of the inferior
alveolar nerve (IAN) and mental nerve.
Inferior alveolar nerve damage can occur during third molar
extraction, implant location, orthognathic surgery, preprosthetic
surgery, salivary gland surgery, local anesthetic injections or during
the resection of benign or malignant tumors.
Injuries to the IAN can be caused also by endodontic treatment
of mandibular molars and premolars when filling material is forced
into the tooth and mandibular canal.
The sensory disturbances that could follow a damage of the IAN
could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and
sometimes a painful anesthesia that strike ipsilateral lower lip, chin,
and teeth. These can undermine life quality by affecting speech,
chewing, and social interaction.
Treatment of these complications is sometimes difficult and could
consist in observation or in surgical decompression of the involved
nerve to relieve the patient’s symptoms and improve sensory recov-
ery. The most debated points are the timing of intervention and the
effective role of decompression in clinical outcome—improvement.
The purpose of this article is to show authors’ experience with 2
patients treated with microsurgical nerve decompression to remove
endodontic material from the mandibular canal and providing also a
comprehensive review of the literature.
Key Words: Endodontic material, endodontic treatment
complications, inferior alveolar nerve injury, microsurgical
decompression
(J Craniofac Surg 2017;00: 00–00)
I atrogenic injury in oral surgery is the most frequent cause of
sensory disturbance in the distribution of the inferior alveolar
nerve (IAN) and mental nerve.1,2
Inferior alveolar nerve damage can occur during third molar
extraction, implant location, orthognathic surgery, pre-prosthetic
surgery, salivary gland surgery, local anesthetic injections or during
the resection of benign or malignant tumors.3– 5
From the Maxillo-Facial Surgery Division, Head and Neck Department,
University Hospital of Parma, Parma, Italy.
Received December 19, 2016.
Accepted for publication January 7, 2017.
Address correspondence and reprint requests to Andrea Varazzani, MD, via
Gramsci 14, 43100 Parma, Italy; E-mail: andrea2787@libero.it
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000003672
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Injuries to the IAN can be caused also by endodontic treatment
of mandibular molars and premolars when filling material is forced
into the tooth and mandibular canal.6
Injuries of the IAN can be caused by 2 mechanisms: the
chemical neurotoxicity of the endodontic paste and/or the mech-
anical pressure due to the filling material pushed into the mandib-
ular canal.7 –12
The sensory disturbances that could follow a damage of the IAN
could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and
sometimes a painful anesthesia that strike ipsilateral lower lip, chin,
and teeth. These can undermine life quality by affecting speech,
chewing and social interaction.13– 16
Treatment of these complications is sometimes difficult and could
consist in observation or in surgical decompression of the involved
nerve to relieve the patient’s symptoms and improve sensory recov-
ery. The most debated points are the timing of intervention and the
effective role of decompression in clinical outcome—improvement.
Due to the retrospective nature of this study, Institution Review
Board (IRB) was not required by our institution.
The purpose of this article is to show our experience with 2
patients treated with microsurgical nerve decompression to remove
endodontic material from the mandibular canal and providing also a
comprehensive review of the literature.
CLINICAL REPORT 1
A 57-year-old man was referred to our department (Maxillo-Facial
Surgery Department of the University Hospital of Parma, Parma,
Italy) for pain and numbness in his left lower lip and chin, which
developed following endodontic therapy of the second left man-
dibular premolar.
The patient’s past medical history was unremarkable. He was a
nonsmoker, had no allergies, and took no medications. He had no
history of systemic diseases or other pathologies that could be
responsible for such symptoms.
The patient reported having had a root canal therapy performed 8
months prior. Three weeks after the dental procedure, he had to
return to his dentist due to a persistent feeling of numbness and pain
to the left side of the mandible and lower lip. The dentist decided to
remove the tooth; however, the symptomatology did not improve
after the extraction. Consequently, he decided to wait for a possible
spontaneous recovery. Eight months later, the patient was referred
to our department for evaluation and treatment for the painful
numbness in the inferior lip.
Clinical examination revealed a diminished sensation to a light
touch in the left mental nerve area. The patient was submitted to
electromyography with blink reflex test and masseter inhibitory
reflex (MIR) test in accordance with electrical stimulation on both
the healthy and the affected side. The tests objectively confirmed a
lower excitability in the left mental nerve.
A panoramic radiograph and a cone-beam computed tomogra-
phy revealed the presence of radiopaque material inside the left
mandibular canal in the region of the second molar extending up to
the mental foramen. A large amount of paste occupied about 2 cm
along the mandibular canal (Fig. 1).
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FIGURE 1. Preoperative orthopantomography showing endodontic material

inside the mandibular canal.

To treat the prolonged symptomatology declared by the patient,

we proposed decompressing the nerve by surgically removing the
endodontic material from the mandibular canal using general
anesthesia.
After the patient consented to surgical treatment, we achieved an
intra sulcular incision from the canine to the mandibular ramus, and
we performed a corticotomy using piezoelectric instrumentation to
identify the IAN. We removed the endodontic material from the
canal nerve and examined the nerve using a surgical microscope
(Fig. 2). There was some endodontic material inside the nervous
sheath, so we performed an incision of the sheath to decompress the
nerve and to remove the endodontic material from the inner part of
the nerve (Figs. 3 and 4).
At the last follow-up appointment the patient reported that he
was completely pain free starting from a few days after the surgery
(Fig. 5).
After 1 year from the operation, the patient underwent a Blink
Reflex Test and an MIR. The tests did not show a difference in the
conduction between the right and left sides of the IAN, confirming
that the symptoms were solved as previously clinically detected.
The patient declared to be satisfied with the surgical operation.
After 18 months of follow-up, the patient complains of a very slight
hypoesthesia of the inferior left lip and reports no episodes of pain
or numbness.
CLINICAL REPORT 2
A 54-year-old woman was referred to our clinic for the evaluation of
persisting left mandibular pain, dysesthesia, and anesthesia after
endodontic therapy in the second left inferior premolar.
The patient’s past medical history was not significant.
FIGURE 3. Intraoperative image showing endodontic material inside the
inferior alveolar nerve sheath.
Her clinical dentist performed the extraction of the tooth 3 days
after endodontic therapy, trying to relieve the patient’s symptoms
without success. After 4 months of observation without improve-
ment, the patient was referred to our department.
Clinical examination revealed a diminished sensation to a light
touch in the left mental nerve area. Electromyography with Blink
Reflex and MIR tests confirmed the clinical finding with a severe
reduction of electrical conduction in the alveolar nerve.
Radiology showed some endodontic material inside the alveolar
canal in the second premolar area with a length of about 2 cm
(Fig. 6).
This patient was submitted for the same procedure as the first
patient; however, the nerve appeared normal at the microscopic
evaluation and incision of nerve sheath was not performed (Fig. 7).
Starting from the third postoperative day, the patient reported to
be free of pain. Sensation, with mild dysesthesias, started to recover
over a 4-month period postprocedure (Fig. 8).

FIGURE 2. Intraoperative image showing endodontic material inside the

mandibular canal. FIGURE 4. Intraoperative image after repositioning of the bone fragment.

2 # 2017 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
FIGURE 5. Postoperative orthopantomography.
After 19 months, the patient reported a good recovery of
sensitivity in her inferior left lip and chin, and the electromyography
confirmed these findings.
DISCUSSION
As already mentioned, iatrogenic injuries are the most common
causes of impairment of alveolar nerve and endodontic treatment is
often involved in such complications.17,18
Above all, second premolar and molars seem to be the most
common teeth involved in these injuries, probably because the
apices of the premolar and molar teeth are often in contact with the
mandibular canal as reported by Dempf et al in 2000.
When the alveolar nerve is damaged, during endodontic treat-
ments and the mandibular canal is accidentally filled with endo-
dontic material, sensory disturbances such as pain, hypoesthesia,
paresthesia, and dysesthesia of the lower lip and chin are the most
commonly reported symptoms. In particular, pain should not be
underestimated because it could severely impair the patient’s
quality of life. It is usually described as highly intensive and
fluctuating with a poor response to common pain therapies. It is
usually accompanied by different degrees of hypoesthesia or
anesthesia, depending on the degree of nerve compression. Symp-
toms are related to both mechanisms already described in the
introduction section: nerve compression and chemical damage of
the nerve as documented by Grötz et al19 in 1998.
Diagnosis has to be performed very carefully to identify the area
of the canal involved and the severity of the symptoms. The
panoramic radiograph is very useful but Gambarini et al20 reported
on how a CT scan is mandatory to evaluate with high precision the
canal, especially when surgery is planned.
Electromyography is not routinely performed in literature
reports, but we strongly suggest this because it provides objective
evaluation of the damage which is very useful, especially when
legal procedures are conducted. Furthermore, this exam also pro-
vides useful information during the follow-up appointment.
Ideal treatment, and especially its timing, is the real key point of
the debate in international literature. In our opinion, as Byun et al
reported in 2015, prompt surgical decompression is strongly
FIGURE 6. Cone-beam computed tomography showing endodontic material
inside the mandibular canal.
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Microsurgical Decompression of IAN
FIGURE 7. Intraoperative picture: circle highlights endodontic material inside
the mandibular canal.
suggested, especially in removing a chemical irritation stimulus
to the nerve as Scala et al described in 2014.21,22
Furthermore, some authors clearly report that early surgical
intervention for nerve damage has generally a better prognosis
than the one for chronic nerve injuries.23,24
Scolozzi et al25 also affirm that chronic paraesthesia has a
favorable prognosis if the paraesthesia results from conduction
block due to compression underlining the importance of chemical
damage removal as soon as possible.
Also Köseoğlu et al26 report that the surgical intervention should
be performed within 3 weeks after the endodontic mishap, because a
longer observation period might increase the risk of irreversible
damage to the IAN.
Despite this amount of evidence, some authors suggest that
‘‘wait and see’’ strategy could be taken into account, and that timing
of surgical procedure has little effect on the success of nerve repair
procedures.27,28
Other studies support also that patients have achieved a satis-
factory outcome without surgical treatment.29,30
In our experience the decision should be made in taking into
account the severity of symptoms, particularly the amount of pain
that severely impairs the quality of the patient’s life. Extension of
canal involvement and timing elapsed from endodontic procedure
(our cutoff is 18 months). Despite these suggestions, a very
dedicated patient’s explanation that clarifies surgical options,
and their expected outcomes, is the real basis of our decision.
FIGURE 8. Postoperative cone-beam computed tomography.
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Concerning surgical procedure, there are different approaches
reported in the literature. Some authors describe a sagittal split
ramus osteotomy to have a better view of the mandibular canal.
Dempf and Hausamen affirm that the mandibular canal should
be opened from the mental foramen to the wisdom tooth because
this mode of opening the mandibular canal has proven less difficult
than opening the canal at the exact site of the lesion and a better
overall impression of the nerve is obtained. These authors state that
if the filling material is only found in the immediate proximity of the
nerve, without having been forced between the fascicles, only one
has to remove the endodontic material, carefully rinse out the
mandibular canal, and remove the epineurium by microsurgical
neurolysis to prevent that the epineurium scars lead to a secondary
compression. If the filling material can be seen inside the nerve, the
disrupted nerve should be resected and the defect has to be bridged
using a nerve transplant.
Our approach consisted in a corticotomy using piezoelectric
instrumentation, only where the endodontic material was present, to
minimize morbidity and having as main goal decompression from
endodontic material rather than mobilization of the nerve. Advan-
tages of piezosurgery are already well known and we strongly
suggest these instruments in such procedures. Use of a microscope
is mandatory in our opinion because it allows careful management
of the nerve, identification of possible sheath violation as in our first
patient, and possible reparation or grafting in case of nerve
continuity disruption.
Results of surgery are often unpredictable both in terms of time
and quality of sensory recovery. Pain control is usually achieved in
a few days and this, in our experience, is an important point in the
treatment planning. Also, in our patients also sensory recovery was
very satisfactory but more studies with larger case series should be
provided to assess the real expectation of this aspect.
CONCLUSION
Surgical decompression of inferior alveolar nerve is a valuable
option for patients suffering from nerve injuries after endodontic
material leaks inside the mandibular canal. Prompt treatment and
minimally invasive surgery using piezoelectric instrumentation and
microscope are, in our opinion, the key point for the success of the
operation. Finally, an accurate patient’s informed consent that takes
into account possibilities and expectations in terms of procedure is
strongly suggested because of the difficult prevision of results.
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