The perception and practice of routine lingual flap retraction in lower third molar surgery among oral and maxillofacial surgeons in Nigeria.

Background: Lingual nerve injury is a known complication of mandibular third molar (M3M) surgery, and retraction of the lingual flap is reported to reduce the incidence of this complication. However, there is no global consensus on the routine retraction of lingual flap. Aim: The aim of the study was to assess the perception and practice of lingual flap retraction amongst oral and maxillofacial surgeons in Nigeria. Materials and Methods: This cross-sectional national survey was conducted amongst 122 oral and maxillofacial surgeons in Nigeria from January 2023 to March 2023 using a validated, structured, self-administered questionnaire. The questionnaire had three sections and 14-item questions. Section A consists of the sociodemographic questions, Section B comprises questions on perception towards lingual flap retraction, whereas Section C consists of questions on the practice of lingual flap retraction. These questionnaires were deployed as an online survey and as hard copies. Both qualitative and quantitative data were analysed. A critical probability level (P < 0.05) was used as the cut-off level for statistical significance. Results: Most of the participants (47.6%) belong to the age group of 31-40 years. The male-to-female ratio was 6:1. Only 12 (9.8%) participants had a positive perception towards routine lingual flap retractions following M3M surgery. Perception of lingual flap retraction was found not to be associated with the demographic variables of the participants (P > 0.05). A total of 95 participants (77.9%) did not raise nor retract the lingual flap during lower third molar surgery. The rate of practice of lingual flap retraction during third molar surgery was not influenced by any of the factors studied (P > 0.05). Conclusion: The majority of oral and maxillofacial surgeons in Nigeria do not agree that routine retraction of the lingual flap is necessary to reduce lingual nerve injury and majority, too, do not practice this in their management of impacted lower third molar.

Lingual Nerve Injury During Impacted Mandibular Third Molar Surgery.

OBJECTIVE: To determine the frequency of lingual nerve injury (LNI) during the surgical removal of mandibular third molar and the associated risk factors. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Oral and Maxillofacial Surgery, Ayub Teaching Hospital, Abbottabad, from January to June 2021. METHODOLOGY: A total of 121 patients were included in this study who had undergone impacted third molar surgery. Data were collected on a proforma via interview. Patients were followed up after 1 week, 1 month, and 3 months of duration. Frequency of LNI and its association with various surgical procedure steps were determined. RESULTS: This study shows that out of 121 patients, frequency of LNI was found to be 3.3% (n=4). The type of impaction (p=0.047), lingual flap retraction (p<0.001), tooth splitting (p=0.029), and longer duration of surgery were found to be significantly associated with it. CONCLUSION: The frequency of LNI during mandibular impacted third molar surgery was 3.3% in this study, and significantly associated with horizontal impaction, lingual flap retraction, tooth splitting, and duration of surgery longer than 30 minutes. KEY WORDS: Lingual nerve injury, Tooth, Impaction, Third molar, Lingual flap retraction, Tooth splitting.

Lingual nerve impairment/injury after retrieval of the displaced mandibular third molar into the floor of the mouth.

Retrieval of the displaced mandibular third molar in the floor of the mouth is challenging as the lingual nerve is always at risk of injury. However, there are no available data to show the incidence of the injury caused by the retrieval. The goal of this review article is to provide the incidence of the iatrogenic lingual nerve impairment/injury caused by the retrieval based on the review of the existing literature. The retrieval cases were collected with the search words below using PubMed, Google Scholar, and CENTRAL Cochrane Library database on October 6, 2021. A total of 38 cases of lingual nerve impairment/injury in 25 studies were eligible and reviewed. Temporary lingual nerve impairment/injury due to retrieval was found in six cases (15.8%) and all recovered between three to six months after retrieval. General anaesthesia and local anaesthesia were used for retrieval in three cases each. The tooth was retrieved using a lingual mucoperiosteal flap in all six cases. The permanent iatrogenic lingual nerve impairment/injury due to retrieval of the displaced mandibular third molar is considered extremely rare as long as the appropriate surgical approach is chosen based on surgeons' clinical experience and anatomical knowledge.

Incidence of lingual nerve damage following surgical extraction of mandibular third molars with lingual flap retraction: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to examine more recent data to determine the extent of lingual nerve injury (LNI) following the surgical extraction of mandibular third molars (M3M). A systematic search of three databases [PubMed, Web of Science and OVID] was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria encompassed studies on patients who underwent surgical M3M extraction using the buccal approach without lingual flap retraction (BA-), buccal approach with lingual flap retraction (BA+), and lingual split technique (LS). The outcome measures expressed in LNI count were converted to risk ratios (RR). Twenty-seven studies were included in the systematic review, nine were eligible for meta-analysis. Combined RR for LNI (BA+ versus BA-) was 4.80 [95% Confidence Interval:3.28-7.02; P<0.00001]. The prevalence of permanent LNI following BA-, BA+ and LS (mean%±SD%) was 0.18±0.38, 0.07±0.21, and 0.28±0.48 respectively. This study concluded that there was an increased risk of temporary LNI following M3M surgical extractions using BA+ and LS. There was insufficient evidence to determine whether there is a significant advantage of BA+ or LS in reducing permanent LNI risk. Operators should use lingual retraction with caution due to the increased temporary LNI risk.

Transient unilateral lingual nerve injury following the use of laryngeal mask airway Supreme: a case report.

Lingual nerve injury rarely occurs after using the laryngeal mask airway (LMA). A 40-year-old woman with no comorbidities visited the hospital for left breast-conserving surgery. Anesthesia was performed using LMA Supreme™. She complained of decreased sensation in the right front part of the tongue postoperatively. She received prednisolone and tongue sensation returned on postoperative day 28. The lingual nerve could be damaged by the LMA, particularly the lateral edge of the tongue base and inner part of the mandible around the third molar. When using the LMA, it is necessary to check the cuff pressure to prevent lingual nerve damage.

Risk Factors for Lingual Nerve Injury Associated With Suspension Laryngoscopy.

PURPOSE: This prospective study was designed to identify risk factors for lingual nerve injury as a complication of suspension laryngoscopy. METHODS: Fifty-six adult patients (19 females and 37 males) who underwent microlaryngeal surgery (MLS) using the suspension laryngoscopy procedure under general anesthesia at our otorhinolaryngology department between January 2016 and January 2018 were enrolled in this study. All operations were performed using only a cold-steel microlaryngeal surgical set, and operations using laser and radiofrequency energy were not included. Unilateral or bilateral paresthesia, numbness of the tongue, and/or a change in taste sensation (dysgeusia) were considered to indicate lingual nerve injury. RESULTS: Operation time and difficulties during intraoperative intubation and/or suspension of the larynx were major risk factors for lingual nerve injury following suspension laryngoscopy ( P = .015 and P = .011, respectively). Difficulties in preoperative flexible fiberoptic examination and intraoperative laryngeal compression were not found as risk factors, and the associations were not significant. Additionally, females showed a higher complication rate of lingual nerve injury following suspension laryngoscopy than males. CONCLUSION: From a medical-legal standpoint, although lingual nerve injury is not a life-threatening complication, it is important to inform patients, especially those expected to undergo long-duration surgery.

Comparison of Subjective and Objective Assessments of Neurosensory Function after Lingual Nerve Repair.

OBJECTIVE: Mandibular third molar extractions are important in oral maxillofacial surgery. Damage to the lingual nerves, although rare, is a possible complication. There are reports of postoperative recovery after lingual nerve repair, but few reports have compared subjective and objective assessments of neurosensory function. Therefore, this study aims to compare subjective and objective assessments of neurosensory function after lingual nerve repair. SUBJECTS AND METHODS: This retrospective cohort study comprised 52 patients with lingual nerve anesthesia after third molar extraction at the Department of Oral and Maxillofacial Surgery, Wakayama Medical University Hospital, Wakayama, Japan, between December 2008 and December 2015. We recorded pre- and postoperative (6 months and 12 months) neurosensory examinations. RESULTS: Patient's subjective assessments of neurosensory function suggested improvement between the preoperative period and 12 months postoperation, although this difference was not significant. Objective assessment based on examination and testing, on the other hand, showed a significant difference in improvement (p < 0.05). CONCLUSIONS: There was no evidence that improvement of subjective preoperative and postoperative assessments was significantly associated with improvement of objective neurosensory assessments after lingual nerve repair. Overall physical condition and background were thought to affect subjective evaluation. Subjective assessment is important in conjunction with objective evaluation because it may reveal dysesthesia that would otherwise be missed. In the future, we will examine those cases in whom subjective assessments showed no improvement although objective assessments showed improvement.

Reconstructive Options for Inferior Alveolar and Lingual Nerve Injuries After Dental and Oral Surgery: An Evidence-Based Review.

PURPOSE: The investigators wanted to evaluate, analyze, and compare the current microsurgical repair modalities (primary repair, autograft, tube conduit, and allograft reconstruction) in achieving functional sensory recovery in inferior alveolar and lingual nerve reconstructions due to injury. METHODS: A literature review was undertaken to identify studies focusing on microsurgical repair of inferior alveolar and lingual nerve injuries. Included studies provided a defined sample size, the reconstruction modality, and functional sensory recovery rates. A Fischer exact test analysis was performed with groups based on the nerve and repair type, which included subgroups of specific nerve gap reconstruction modalities. RESULTS: Twelve studies were analyzed resulting in a sample consisting of 122 lingual nerve and 137 inferior alveolar nerve reconstructions. Among the nerve gap reconstructions for the lingual nerve, processed nerve allografts and autografts were found to be superior in achieving functional sensory recovery over the conduits with P values of 0.0001 and 0.0003, respectively. Among the nerve gap reconstructions for the inferior alveolar nerve, processed nerve allografts and autografts were also found to be superior in achieving functional sensory recovery over the conduits with P values of 0.027 and 0.026, respectively. Overall, nerve gap reconstructions with allografts and autografts for inferior alveolar and lingual nerve reconstruction were superior in achieving functional sensory recovery with a P value of <0.0001. CONCLUSIONS: The data analyzed in this study suggest that primary tension-free repair should be performed in inferior alveolar and lingual nerve reconstructions when possible. If a bridging material is to be used, then processed nerve allografts and autografts are both superior to conduits and noninferior to each other. In addition, allografts do not have the complications related to autograft harvesting such as permanent donor site morbidity. Based on the conclusions drawn from these data, we provide a reproducible operative technique for inferior alveolar and lingual nerve reconstruction.

Transoral sialolitectomy combined with sialoendoscopy versus open submaxilectomy for the management of hilar lithiasis of the submandibular gland. / Sialolitectomía transoral combinada con sialoendoscopia versus submaxilectomía abierta para el manejo de litiasis hiliares de la glándula submaxilar.

INTRODUCTION: The treatment of salivary obstructive pathology by minimally invasive techniques has been an object of assessment by different studies for decades. Lithiasis at the level of the salivary duct will be the most frequent cause of obstruction, representing more than 50% of the pathology of the major salivary glands and almost 80% of these affecting the Wharton duct. MATERIAL AND METHODS: A prospective study comparing the results of combined transoral sialolitectomy (CTS) and open submaxillectomy techniques by cervicotomy in 2 groups of patients treated by lithiasis at the level of the hilum of the submaxillary gland. RESULTS: 22 patients were included in the study 16 (72.7%) were men and 6 (27.3%) were women, the average age was 54.41 years ± 12.75 (Min: 30/Max: 77). Regarding the variables associated with the disease: average lithiasis, size of the stone, hospital stay, lingual nerve alteration or complications for both techniques, differences were not found between both groups. There were only statistically significant differences in the average stay in favor of the CTS (P=.001). CONCLUSION: The minimally invasive approaches to the salivary ductal system, associated or not with sialoendoscopy, can be efficacy and can be associated with lower number of complications. The natural tendency should be aimed to gradually replacing open sialoadenectomy techniques, reserving its indication for the treatment of tumor pathology.

Coronectomy of mandibular third molars: a clinical and radiological study of 231 cases with a mean follow-up period of 5.7years.

Coronectomy is a widely accepted treatment for mandibular third molars that are in close relationship to the mandibular canal. However, long-term studies on morbidity following this procedure have not been presented. The aim of this study was to examine the long-term morbidity after coronectomy, with sensory disturbances of the inferior alveolar nerve (IAN) and root migration as the primary outcome variables. A total of 231 mandibular third molar coronectomies were performed in 191 patients with a mean follow-up period of 5.7years (range 1-12years). The prevalence of IAN injury was 1.3%, and 3.5% of the retained roots were removed. None of the reoperations to remove the retained roots caused IAN impairment. Infections occurred in 11.7% of the cases and all were treated with antibiotics. Overall, 97% of the retained roots showed signs of migration and 65% showed signs of rotation. Therefore, coronectomy of the mandibular third molars with an intimate relationship to the mandibular canal seems to be a safe treatment modality with a good long-term prognosis.

Objective Assessment of Lingual Nerve Microsurgical Reconstruction.

Lingual nerve (LN) injury is one of the most serious consequences of oral surgery. Prompt microsurgical reconstruction of the nerve can alleviate most of those symptoms leading to satisfactory functional recovery.Thirty-five patients with partial to complete LN injury underwent surgery in the period between January 2006 and May 2015. All patients underwent a preoperative clinical and neurological evaluation with the assessment of lingual tactile and pain sensory thresholds and masseteric inhibitory reflex.All patients underwent explorative surgery and direct microneurorrhaphy of distal and proximal stumps in case of complete lesion, while the removal of traumatic neuroma and the following microneurorrhaphy of distal and proximal stumps of the injured nerve was performed in case of incomplete lesion. Nerve grafting has always been avoided because of distal stump mobilization obtained by severing the submandibular branch of the LN.All patients but 1 exhibited good recovery of tongue sensation, never complete, both clinically and electrophysiologically: recovery of the excitability of masseteric inhibitory reflex suppression components SP1 and SP2 was observed, often with increased latencies but consistent with a functional recovery.All patients feeling pain preoperatively experienced complete relief of algic symptoms.The early microsurgical approach is the most suitable choice for the treatment of LN injuries.

A pilot study on the effects of direct contact of two different surgical burs on the cadaveric lingual nerve.

The lingual guttering technique for third molar surgery carries the risk of injury to the lingual nerve if the surgical bur comes into direct contact with it. This study investigated the extent of nerve injury caused by two different burs, a tungsten carbide bur and the Dentium implant bur; the latter is designed to be soft tissue friendly. This study also examined whether ultrasound and magnetic resonance imaging are able to detect any injury inflicted. This cadaveric research involved subjecting 12 lingual nerves to the drilling effect of two different burs at two different speeds. The amount of damage caused was measured using different imaging modalities to assess their ability to detect the injury inflicted. At high speed, the Dentium bur caused a deeper and wider laceration than the carbide bur. At low speed, the laceration depths and widths caused by the two burs did not differ significantly. Ultrasound scanning was able to detect the nerve laceration at damaged sites observed using optical coherence tomography. Thus, a carbide bur (at low speed) would be preferable for lingual bone guttering, as it causes less laceration to the lingual nerve. In the event of a suspected injury, ultrasound scanning would provide an objective evaluation of the amount of nerve damage in vivo.

Traumatic Lingual Hematoma Resulting in Bilateral Temporal Mandibular Joint Dislocations.

BACKGROUND: Lingual hematoma (LH) is a relatively uncommon entity seen after both medical and traumatic etiologies. Regardless of the cause, the feared complication is acute airway obstruction. CASE REPORT: Our case involves a 39-year-old man who presented to the Emergency Department via emergency medical services with an enlarging LH after an unwitnessed fall, suspected to be an alcohol withdrawal seizure. The bleeding was likely exacerbated by previously undiagnosed thrombocytopenia. Airway stabilization was rapidly established via nasotracheal intubation after standard intubation techniques were deemed unfeasible. Despite correction of the coagulopathy, the LH continued to expand, resulting in bilateral tympanomandibular joint (TMJ) dislocations. To our knowledge, this complication has not been previously reported as a complication of LH. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite being a relatively uncommon condition, LH has the potential to result in life-threatening airway obstruction with limited airway options. Prompt airway stabilization should be the first priority upon diagnosis. A rapidly evolving LH can limit standard orotracheal rapid sequence intubation options, and may require alternative airway procedures. Additionally, ongoing lingual swelling after airway stabilization has now been shown in our case to result in bilateral TMJ dislocations. Concurrent management of reversible coagulopathy may help prevent this complication or reduce its severity.

Incidence and risk factors for postoperative lingual neuropraxia following airway instrumentation: A retrospective matched case-control study.

BACKGROUND: Lingual nerve injury or neuropraxia is a rare but potentially serious perioperative complication following airway instrumentation during general anesthesia. This study explored the the incidence and perioperative risk factors for lingual nerve injury in patients receiving laryngeal mask (LMA) or endotracheal (ETGA) general anesthesia in a single center experience. METHODS AND RESULTS: All surgical patients in our hospital who received LMA or ETGA from 2009 to 2013 were included, and potential perioperative risk factors were compared. Matched controls were randomly selected (in 1:5 ratio) from the same database in non-case patients. A total of 36 patients in the records had reported experiencing tongue numbness after anesthesia in this study. Compared with the non-case surgical population (n = 54314), patients with tongue numbness were significantly younger (52.2±19.5 vs 42.0±14.5; P = 0.002) and reported lower ASA physical statuses (2.3±0.7 vs 1.6±0.6; P<0.001). Patient gender, anesthesia technique used, and airway device type (LMA or ETGA) did not differ significantly across the two groups. A significantly higher proportion of patients underwent operations of the head-and-neck region (38.9 vs 15.6%; P = 0.002) developed tongue numbness after anesthesia. Multivariate logistic regression analysis indicated that head-and-neck operations remained the most significant independent risk factor for postoperative lingual nerve injury (AOR 7.63; 95% CI 2.03-28.70). CONCLUSION: The overall incidence rate of postoperative lingual neuropraxy was 0.066% in patients receiving general anesthesia with airway device in place. Young and generally healthy patients receiving head-and-neck operation are at higher risk in developing postoperative lingual neuropraxy. Attention should be particularly exercised to reduce the pressure of endotracheal tube or laryngeal mask on the tongue during head-and-neck operation to avert the occurrence of postoperative lingual neuropraxy.

Mesiolingual root rotation for horizontal mandibular third molar extraction: position classification and surgical simulation.

Extracting horizontal mandibular 3rd molars face considerable difficulty due to the large bone and adjacent tooth resistances. This study aims at evaluating the effectiveness of a novel method-mesiolingual root rotation to extract wisdom teeth of this type. In this study, 73 horizontal teeth extracted using piezosurgery were reviewed and classified based on impaction depth: position I, II, III refers to the highest portion of the crown on a level with upper 1/3, middle 1/3, lower 1/3 of the 2rd molar's root. Based on the surgical simulations on their 3D CBCT reconstructions, traditional method(crown distal rotation) and novel method(root mesiolingual rotation) are applied. 79.17% of teeth in position I and 57.89% of teeth in position II were designed using traditional method, 83.33% teeth in position III were designed using the novel method(p < 0.05). The surgeries were performed according to the designs. Two cases in position II using traditional method were found temporary inferior alveolar nerve(IAN) injury; while only one case in position III using novel method got temporary IAN and lingual nerve injury. Our study suggested that root mesiolingual rotation is an effective method to extract the horizontal mandibular 3rd molars, especially the deep impacted ones.

Wisdom tooth extraction causing lingual nerve and styloglossus muscle damage: a mimic of multiple cranial nerve palsies.

The combination of tongue hemianaesthesia, dysgeusia, dysarthria and dysphagia suggests the involvement of multiple cranial nerves. We present a case with sudden onset of these symptoms immediately following wisdom tooth extraction and highlight the clinical features that allowed localisation of the lesion to a focal, iatrogenic injury of the lingual nerve and adjacent styloglossus muscle.

Prevention of Lingual Nerve Injury in Third Molar Surgery: Literature Review.

PURPOSE: To identify any factors that could aid the surgeon in preventing or minimizing the risk of lingual nerve injury during third molar surgery. MATERIALS AND METHODS: Electronic research was carried out on the correlation between lingual nerve damage and lower third molar surgery (topographic anatomy, surgical technique, and regional anesthesia) using PubMed, Scopus, and Cochrane central databases. The research included only articles published in English up to February 2016. RESULTS: Lingual nerve anatomy varied greatly: direct contact between the lingual nerve and the third molar alveolar wall was reported in a wide range of cases (0 to 62%) and the nerve was located at the same level or above the top of the ridge in 0 to 17.6% of cases. No detailed data were found on the actual incidence of lingual nerve injury resulting from local anesthesia by injection. Permanent lingual nerve damage did not show statistically relevant differences between the simple buccal approach and the buccal approach plus lingual flap retraction, although the latter was statistically associated with an increased risk of temporary damage. Lingual spit technique was statistically associated with an increased risk of temporary nerve damage than the buccal approach with or without lingual flap retraction. For permanent damage, no statistically relevant differences were found between the lingual split technique and the buccal approach with lingual flap retraction. Compared with tooth sectioning, the ostectomy was strongly statistically associated with permanent lingual nerve damage. CONCLUSIONS: Results should be interpreted with extreme caution because of the considerable heterogeneity of the data and the considerable influence of several anatomic and surgical variables that were closely related, but difficult to analyze independently. It seems preferable to avoid lingual flap elevation, except in selected cases in which the presence of more than 1 unfavorable surgical variable predicts a high risk of nerve injury. Tooth sectioning could decrease the extent of the ostectomy or even, in some cases, prevent it, potentially acting as a protective factor against lingual nerve injury.

Neuropathic Pain Due to Iatrogenic Lingual Nerve Lesion: Nerve Grafting to Reduce Otherwise Untreatable Pain.

Iatrogenic lingual nerve lesion is a well-known and unfortunate complication after mandibular third molar removal. Occasionally, the nerve injury can cause severe neuropathic pain.Here, the authors present the history of 2 patients with lingual nerve injury due to mandibular third molar removal, and with severe neuropathic pain in the craniomandibular region. Pharmacotherapy and physiotherapy did not reduce the pain, and ultimately, the lingual nerve was surgically explored. Scar tissue and a lingual nerve neuroma were observed and resected in both patients.In the first patient, the gap between the nerve stumps was bridged with an autologous sural nerve graft. In the second patient, some continuity of the lingual nerve was preserved and the resected part was substituted with an autologous sural nerve graft. Significant pain reduction was achieved in both patients and no further medical treatment was necessary at the end of follow-up.These reports show that lingual nerve reconstruction can be a successful therapy in patients experiencing severe neuropathic pain after iatrogenic lingual nerve injury. Different treatment options for neuropathic pain due to lingual nerve injury are discussed.

Lingual nerve injury in association with sagittal ramus osteotomy and bicortical screw fixation: a review of 523 procedures in 262 subjects.

The purpose of this study was to assess the frequency of irreversible lingual nerve (LN) injury in patients undergoing sagittal ramus osteotomies (SRO) with bicortical screw fixation. A retrospective cohort study of patients treated by a single surgeon was performed (follow-up 2-11 years). The sample consisted of a series of subjects with a bimaxillary dentofacial deformity (DFD). The SRO and bicortical screw fixation techniques were consistent. The primary outcome variable was the prevalence of irreversible LN injury. Two hundred sixty-two subjects undergoing 523 SROs with bicortical screw fixation met the inclusion criteria. Average age at operation was 25 years (range 13-63 years) and there were 134 females (51%). The majority of SROs were fixated with three bicortical screws (92%). Simultaneous third molar removal was done in 209 of the 523 SROs (40%). For primary mandibular deficiency subjects (n=40), the mean mandibular advancement was 11.0mm (range 5-17mm), with 42.5% undergoing counter-clockwise rotation. In the study group (n=523 SRO's) there was one irreversible LN injury (<1%). This study confirmed a lack of association of LN injury at the time of SRO with sex, age at operation, simultaneous removal of a third molar, use of bicortical screw fixation, pattern of DFD, and extent of mandibular advancement.

Use of Fibrin Glue as an Adjunct in the Repair of Lingual Nerve Injury: Case Report.

This report describes a case of lingual nerve injury repair using a novel technique in which Tisseel fibrin glue was used to stabilize an Axoguard nerve conduit placed around the site of primary neurorrhaphy to decrease the number of sutures required for stabilization. Five months postoperatively, the patient subjectively had increased sensation and improved taste in the left lingual nerve distribution. At neurosensory examination, the patient exhibited functional neurosensory recovery (S3+ on the Medical Research Council Scale).