Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

Investigation of nerve injury after lower third molar removal

Z. Moosa1 & N. Malden1
1
Department of Oral Surgery, Edinburgh Dental Institute, Edinburgh, UK

Key words: Abstract

inferior alveolar nerve, lingual nerve,
mandibular third molars, nerve injury, Aim: This study was carried out to investigate the number of patients
surgical extraction who developed a nerve injury (inferior alveolar nerve or lingual
nerve) following lower third molar removal at the Edinburgh Dental
Correspondence to: Institute.
Zuhair Moosa
Material and methods: A prospective cross sectional study was
Department of Oral Surgery, Edinburgh
conducted at the Edinburgh Dental Institute. A total of 218 patients who
Dental Institute, Edinburgh, UK
Tel.: 0 131 536 1129 underwent 236 mandibular third molar extractions were included in the
email: zuhairhmoosa@gmail.com study. They all signed a consent form and agreed to be a part of the
study. All of them were followed up with a telephone interview 1 week
Accepted: 4 April 2017 post operatively and were asked if they had any altered sensations in
the lip, chin and/or tongue. If they did, they were asked to attend for a
doi:10.1111/ors.12284
clinical assessment.
Results: Of the 218 patients, 13 patients (5.5%) reported altered
sensations in the telephone interview. Eleven reported altered sensations
in the lip and/or chin. Two of the patients reported altered sensations in
the tongue. So inferior alveolar nerve injury incidence was 4.7% while
lingual nerve injury incidence was 0.9%. Eleven of the injuries were
temporary and the other two patients remain under review as they are
still reporting some altered sensations.
Conclusion: The result correlates with the incidence of nerve injury
available in the literature. However, to get a more accurate result, a
study with a larger number of patients needs to be carried out.

Clinical relevance Practical implications

Scientific rationale for study
This study was a prospective study which was carried
out to investigate the incidence of nerve injury after
lower third molar removal at the Edinburgh Dental
Institute.
Principal findings
The study showed that after lower third molar
removal at the Edinburgh Dental Institute, the
incidence of inferior alveolar nerve injury was
4.7% and the incidence of lingual nerve injury
was 0.9%.
Nerve injury can have serious implications on a
patient’s quality of life and it is of utmost importance
for the clinician to be able to consent the patient
regarding this before the procedure and also know
how to manage the patient if nerve injury occurs.
Introduction
Oral surgeons perform the surgical removal of lower
third molars frequently in their everyday practice. As
with other surgical procedures, lower third molar
removal can have post-operative complications. The
standard transient or temporary complications are
post-operative pain, bleeding, infection, swelling or

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© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Nerve injury after lower third molar removal
bruising on the operated side and difficulty in mouth
opening (trismus). The complication of damage to
the inferior alveolar nerve (IAN) and the lingual
nerve (LN) however can be considered a more seri-
ous and permanent disability.
If IAN injury occurs, the patient is most likely to
experience sensations which could be classified as
‘tingling’, ‘numbness’ or as a burning or painful sen-
sation affecting the ipsilateral lower lip, chin, gingi-
vae and teeth1. If LN injury occurs, the patient
might notice pain, numbness, burning or tingling in
half of the tongue on the operated side and another
symptom could be taste loss from that side2. Since
there is a chance of nerve injury occurring, any
patient undergoing lower third molar removal
should be consented and have an explanation in
more detail about the symptoms in the likely event
of an IAN or LN injury. It should be mentioned that
they might have altered or abnormal sensations in
the lower lip, half of the tongue, chin, gingivae and
teeth on the operated side. The areas could some-
times be painful as well.
The reported incidence of injury varies consider-
ably in the literature. Umar et al. mentions in his
paper that ‘the frequency of occurrence of this com-
plication, i.e.: IAN injury, is reported in the literature
to vary widely, from 0% to as high as 17.4%1. Fraf-
jord and Renton say that IAN injury is reported to
occur in up to 3.6% of cases permanently and 8% of
cases temporarily3. Loescher, Smith and Robinson
mention that in 1.3–7.8% of procedures, IAN func-
tion is disturbed. Most patients, however will recover
and 0–2.2% have permanent disturbances. Although
in the case of LN, the frequency of injury reported is
0.2–22% in the early post-operative period and 0–
2% permanent damage has been recorded2. P. P.
Robinson et al. says that about 4% of patients sustain
IAN injury during removal of lower third molars and
approximately 7% of operations cause LN injury4.
John R. Zuniga says that the incidence of permanent
injury to the IAN and LN after lower third molar
removal falls in the range of 0.4–25% and 0.04–
0.6% respectively5. Queral-Godoy et al. carried out a
study to calculate the incidence of IAN injury follow-
ing lower third molar removal. In the study 4995
extractions were done. Out of those, 55 patients
showed IAN alterations. So according to their study,
the proportion of extractions resulting in IAN dam-
age was 1.1%6. L. K. Cheung also carried out a simi-
lar study in which 4338 extractions were carried
out. Only 15 of those extractions resulted in IAN
related neurosensory deficits and 30 extractions
resulted in LN related deficits. So the incidence of
2 Oral Surgery
Moosa & Malden
IAN injury or damage after lower third molar
removal was 0.35% and the incidence of LN injury
or damage was 0.69% according to their study7.
Another similar study was also carried out by Jerjes
et al. Their study included 3236 patients who under-
went lower third molar removal. Their study showed
that at one month after the extraction, the incidence
of IAN paresthesia was 1.5% and the incidence of
LN paresthesia was 1.8%. They also mention that
these figures decreased over time and 18–24 months
post operatively, the incidence of permanent dys-
function of the IAN was 0.6% and that of LN was
1.1%8.
The aim of this study was to record the incidence
of IAN injury and LN injury following lower third
molar removal at the Edinburgh Dental Institute.
These findings were then compared to the values
available in the literature to ensure that the institute
was not reporting a high number of nerve injury
incidents.
Materials and Methods
This study was a prospective cross sectional study
investigating the post-operative outcomes following
lower third molar removal. It was considered by the
local quality improvement team and given approval
as a clinical audit. Ethical approval was not required
since it was an observational study without any
interference with the treatment protocols followed
by Edinburgh Dental Institute (EDI).
All patients who were referred to the EDI for
lower third molar removal were asked to take part
in the study. After a power calculation which was
done in correlation with a statistician at the institute,
for a margin of error of 5%, 218 patients were
needed to represent the total number of 500
patients, who are seen in 1 year at EDI. This study
started in October 2014 and all patients were con-
sented up until the required number of 218 patients
was met. A total number of 298 patients were con-
sented out of which 80 failed to answer the follow
up calls which consequently led to the required
number of 218 patients.
Exclusion criteria from the study were: coronec-
tomy cases, cases performed under general anaesthe-
sia in another hospital, simultaneous removal of
other mandibular teeth, personal reasons to not be
in the study and patients that required translators
(language barriers). All of the patients who agreed to
take part in the study signed a consent form before
the procedure and agreed to have a telephonic inter-
view after the procedure.
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© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Moosa & Malden
It should be noted that cases which were consid-
ered as high risk for nerve injury (i.e.: diversion of
the mandibular canal, darkening of the roots and/or
loss of the white lines of the canal) after radio-
graphic assessment from OPG, were sent for a CBCT
scan. If there was a very close relationship between
the nerve canal and the roots, then these cases were
planned as a coronectomy procedure and not
included in the study. If no close relationship was
seen on the CBCT, the case was treated as a low risk
case and included in the study.
On the day of the procedure, a data collection
sheet was filled out by the operator. This sheet con-
tained patients’ personal data, medical history, smok-
ing status and use or not of oral contraceptive pills
for females. The difficulty index of each extraction
according to the clinicians’ perspective was also
noted. They were classified into four categories:
Grade I: Simple extraction (no flap raised), Grade II:
Soft tissue impaction (flap raised, no bone removal),
Grade III: Easy surgical (flap raised, with bone
removal) and Grade IV: Difficult surgical (a lot of
bone removed + increased surgical time). Radiologi-
cal assessment was done using the Pederson diffi-
culty index (Table 1). It includes the angulation of
the tooth and the Pell and Gregory classification,
that is, the depth of the impaction (level A, B and
C) and the position of the tooth in relationship with
the ramus (Class I, II and III). The assessment was
carried out at a later date by two blind assessors. If
there was a dispute, a third assessor was also present
to help with the decision. The assessment was classi-
fied into three categories: minimally difficult, moder-
ately difficult or very difficult.
Table 1 Pederson Difficulty Index
Difficulty index for removal of impacted mandibular third molar
Classification
Angulation
Mesioangular
Horizontal/Transverse
Vertical
Distoangular
Depth
Level A
Level B
Level C
Ramus relationship
Class I
Class II
Class III
Difficulty index very difficult: 7–10, moderately difficult: 5–7, minimally
difficult: 3–4.
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© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Nerve injury after lower third molar removal
All grades of staff including consultants, specialists,
specialist registrars, postgraduate students and senior
house officers performed the procedures. All proce-
dures were done either under local anaesthesia alone
or local anaesthesia with intravenous sedation. All
the surgeries followed the aforementioned proce-
dure: Anaesthesia using lidocaine 2% + adrenaline
1:80 000 for inferior alveolar nerve block together
with articaine 4% + adrenaline 1:100 000 for local
infiltrations around the tooth. A preoperative rinsing
with 0.2% chlorhexidine mouthwash for 30–40 sec-
onds was followed. For surgical extractions a
mucoperiosteal flap was raised with minimal inter-
ference of lingual soft tissues9 and bone removal
and/or tooth sectioned with a medium-speed hand
piece under sufficient sterile solution irrigation; after
tooth removal sockets were irrigated with saline.
Flap closure was performed using 3-0 Vicryl Rapid
(Ethicon) sutures. Antibiotics were not prescribed
routinely to patients and appropriate post-surgical
instructions were given to patients both verbally and
in written form. In case of any emergency or exces-
sive pain, patients could seek advice from their den-
tists, from the oral surgery department or from an
emergency dental centre if it was out of hours’ time.
The results of the investigation were correlated
with different factors, that is, skills of the operator,
difficulty index of the extraction according to the
clinicians’ perspective and difficulty index of the
extraction according to radiographic assessment
using the Pederson difficulty index.
The patients were followed up by a telephone con-
sultation around 1 week post-operatively. This
method was chosen to facilitate both the patient and
the clinicians mainly because it is inconvenient for
patients to come back for a review appointment,
although it is easier to answer set questions via
phone. The telephone call also allows more data to
Difficulty index value be collected and is more cost effective10,11.
In the telephone interview, patients were asked
1 about altered sensations in the lip, chin and/or ton-
2 gue. If they were experiencing any altered sensa-
3 tions, they were asked to come in for a clinical
4
assessment. The telephone interview was conducted
1
by any one of the three authorised assessors (post
2 grad students in the Oral Surgery department) who
3 were available at the time and they all had a script
of the same questions to ask the patients.
1 In the clinical assessment, different tests were used
2 to monitor recovery of the nerve and the results
3
recorded. The tests used were light touch sensation,
pin prick sensation and two point discrimination
tests2,12.
3
Nerve injury after lower third molar removal
Statistical analysis was conducted using Chi-
squared test, independent samples student’s t-test
and Mann-Whitney U test. Results were considered
significant if P values were less than 0.05. SPSS for
Windows (release 21) was used to conduct statistical
testing (SPSS Inc., Chicago, IL, USA).
Results
Of the 298 patients that were consented and were
called back, 218 patients answered the calls. So the
response rate of the telephone call follow up was
73.2%.
Of the 218 patients included in the study, 119
were females (54.6%) and 99 were males (45.4%).
Eighteen of them had bilateral extractions and thus
a total of 236 third molar removals were investi-
gated. The patients’ age varied between 18 and
80 years old with the mean of 32.4. The mean age
of men mean age was 33.6 (range 18–78) and the
mean age of women was 31.5 (range 19–80).
Among the patients, 182 (83.5%) were healthy
and 36 (16.5%) had systemic disorders. The most
common medical condition was asthma (18
patients), followed by hypothyroidism (four patients)
and diabetes type II (three patients).
According to clinicians’ perspective, 49 extractions
(20.8%) were Grade I, 13 (5.5%) were Grade II, 118
(50%) were Grade III and 56 (23.7%) were Grade
IV.
According to the difficulty index, 67 extractions
(28.4%) were minimally difficult, 161 extractions
(68.2%) were moderately difficult and eight extrac-
tions (3.4%) were very difficult.
A total of 85% of the extractions (n = 200) were
carried out by junior clinicians (senior house officers
or postgraduate students) and only 15% of the
extractions (n = 36) were carried out by senior clini-
cians (consultants, specialists or specialist registrars).
Incidence of nerve injury
Thirteen of the 218 (6%) patients reported altered
sensations in the telephone interview after a week.
Eleven of these patients mentioned altered sensa-
tions in the lip and/or chin, that is, IAN injury while
two of the patients had altered sensations in the ton-
gue, that is, LN injury.
As the total number of teeth extracted was 236,
the incidence of nerve injury following lower third
molar removal was 5.5%. Incidence of IAN injury
was 4.7% and incidence of LN injury was 0.9%. Ele-
ven of the nerve injuries were temporary. Five of
4 Oral Surgery
Moosa & Malden
the patients mentioned that the altered sensations
lasted for a week, while six of the patients said that
the altered sensations lasted for about a month
before returning to normal. Two of the patients are
still being followed up as they still have altered sen-
sations. Both of them report that the altered sensa-
tions were decreasing.
Statistical analysis was carried out to investigate if
there was any relationship between the incidence of
nerve injury and different factors, that is, gender of
the patient, age of the patient, skills of the operator,
the difficulty of the extraction according to the clini-
cian’s perspective and according to the difficulty
index.
Gender
Of the 13 patients that reported altered sensations, 3
(2.9%) were male and 10 (7.6%) were females.
There was no association between gender and nerve
injury incidence (v2 = 2.46, df = 1, P = 0.117).
Age
The age range of patients who had a nerve injury
was from 21 years to 48 years, mean age being 30.9.
The mean of whose reporting nerve injury was
30.9 years, compared with 32.4 years for those with-
out nerve injury [Student’s t test = 0.409.
P = 0.683 (not significant)].
Operator skills
Nine of 200 (4.5%) teeth that had been removed by
a junior clinician resulted in nerve injury and four
of 36 (11.1%) teeth that had been removed by a
senior clinician resulted in nerve injury (Fig. 1)
[v2 = 2.37, df = 1, P = 0.124 (not significant)]. It
should be noted that the cases performed by senior
250
4.5%
9
200
No. of patients
150
100 191
11.1%
50
4
32
0
Junior clinician Senior clinician
No nerve injury Nerve injury
Figure 1 Incidence of nerve injury according to the skills of the
operator
 (2017) –.
© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Moosa & Malden
clinicians 50% of the teeth were classified as Grade
4, while only 19% of the teeth extracted by junior
clinicians were classified as Grade 4. So that means
that the senior clinicians tended to carry out the
more difficult extractions.
Clinical difficulty according to operator’s
perception
In the extractions classified as Grade I, one of 49
(2.0%) extractions resulted in nerve injury; in those
classified as Grade II, two of 13 (15.4%) resulted in
nerve injury; in those classified as Grade III, nine of
118 (7.6%) resulted in nerve injury and in those
classified as Grade IV, one of 56 (1.8%) resulted in
nerve injury (Fig. 2). Mann-Whitney U test =
1342.5. P = 0.65 (not significant).
According to the difficulty index
In the extractions classified as minimally difficult,
five of 67 (7.5%) extractions resulted in nerve
injury. In those classified as moderately difficult,
eight of 161 (5%) extractions resulted in nerve
injury. None of the extractions classified as very dif-
ficult resulted in nerve injury (Fig. 3) [Mann-Whit-
ney U test = 1235.5. P = 0.27 (not significant)].
Discussion
Many factors can be considered when assessing the
chances of damage or injury to the IAN or LN. Some
of these factors are: age of the patient, difficulty of
the operation, operator skills and proximity of the
tooth to the IAN canal.3 In the majority of cases,
injury to the nerve is reversible, however, perma-
nent damage cannot be ruled out.
The response rate of the telephone call follow up
was 73.2% as we were unable to contact 80 of the
140
120
100
No. of patients
80 2%
60
1
40
15.4%
20 48
2 of nerve injury not only did not increase but in
0
11
Grade 1 Grade 2
No nerve injury
Figure 2 Incidence of nerve injury according to operators’ perception
of the clinical difficulty of the extraction
Oral Surgery  (2017) –.
© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Nerve injury after lower third molar removal
180 5%
160 8
140
No. of patients
120
100 7%
80 153
5
60
40
62 0%
20
0 8
Minimally difficult Moderately difficult Very difficult
No nerve injury Nerve injury
Figure 3 Incidence of nerve injury according to difficulty index
298 patients. Multiple attempts were made to con-
tact these patients. If we were unable to contact
them within the second week, they were excluded
from the study. It should be noted that they were
asked to tell us the most appropriate time they
wished to be contacted at and they were mostly
called during those times. One of the reasons for
patients not answering could be because the number
used to call was a private number which a lot of
patients choose not to answer. This also meant that
the patients were not able to call back. Keeping in
mind that 80 people could not be contacted, there is
a possibility that some of them might have had a
nerve injury. However, an assumption was made
that since none of these 80 patients came back, they
probably did not have any nerve damage. And even
if they did, it was most probably temporary. Never-
theless, there is always a chance that the actual inci-
dence of nerve injury might have been higher than
recorded.
When considering the skills of the operator, it may
appear from the study that procedures performed by
experienced operators had a higher incidence of nerve
injury. However, it should be kept in mind that the
senior clinicians were mostly operating on difficult
extractions while the simple extractions were usually
7.6% carried out by the junior clinicians. Therefore, a high
9
bias exists and a proper analysis cannot be made from
the results.
When considering the difficulty of the operation,
0.79%
surprisingly, the results contradict most of the
109 1 available literature. According to the study, as the
difficulty of the procedure increased, the incidence
55
some of the classifications it decreased as well. This
Grade 3 Grade 4
could be due to the fact that a similar number of
Nerve injury
cases were not taken in each classification and the
operator skills also varied for different classifica-
tions.
5
Nerve injury after lower third molar removal
Close proximity of the IAN canal should be consid-
ered as a high risk factor but as the cases that were
considered as high risk had a CBCT arranged and
usually an alternate treatment plan such as a coro-
nectomy was arranged these cases were not included
in the study.
Conclusion
In conclusion, the incidence of IAN injury was 4.7%
and the incidence of LN injury was 0.9%. This is
consistent with the incidence that is reported in the
literature. However, it should be kept in mind that
the study carried out had a small number of patients
with a low incidence of nerve injury outcomes. This
was due to time limitations. To investigate the inci-
dence of nerve injury further and get a more accu-
rate result, a study with a larger number of patients
should be carried out.
Conflict of interest
None of the authors has any conflict of interest to
disclose.
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© 2017 The British Association of Oral Surgeons and John Wiley & Sons Ltd