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Original Article

Sensory nerve paresthesia following third molar surgery:

Effectiveness of an evidence based protocol
Mohanavalli Singaram, Venkesana Balakrishnaraja Krishnakumararaja, Sasikala Balasubramaniam,
Elavenil Paneerselvam, Poornima Ravi, Gayathri Gopi
Department of Oral and Maxillofacial Surgery, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India

ABSTRACT
Objective: To assess the incidence of inferior alveolar and lingual nerve paresthesia
following third molar surgeries and to assess the effectiveness of a set departmental protocol
for reducing the incidence of these paresthesia. Study Design: The study included 110
patients who underwent surgery for third molar removal. All cases followed a protocol which
included using a standard Wards incision, raising a lingual flap, use of minimal ostectomy
and tooth sectioning in all cases. A standardized data form was used to record the patients
age, sex, Pedersons difficulty index, distance between the root apices and inferior alveolar
canal, the length of the redline and operating time. Results: Postoperative inferior alveolar
nerve paresthesia occurred in five cases (4.5%) and lingual nerve paresthesia occurred
in one case (0.9%). Paresthesia was significantly related to the duration of the surgical
procedure, but unrelated to the other variables recorded. Conclusion: The current protocol
followed appears to be effective in reducing the incidence of inferior alveolar and lingual
nerve paresthesia to an acceptable level even in the presence of high risk factors.
Key words: Impacted third molar, inferior alveolar nerve, lingual nerve, paresthesia

INTRODUCTION
Impacted teeth are extremely common in the South Indian
population, with incidence of 41.2%.[1] The removal of
impacted third molars is therefore one of the most commonly
performed oral surgical procedures, especially in teaching
institutions. The most distressing complication of third
molar removal is lingual and inferior alveolar nerve damage,
which may lead to temporary or permanent paresthesia.
The incidence of such paresthesia varies in literature, from
Address for correspondence:
Dr. S. Mohanavalli,
40/8, Venus Apartments, Kamaraj Nagar, 3rd Street,
Choolaimedu, Chennai - 600 094, Tamil Nadu, India.
E-mail: mona13omfs@gmail.com
Access this article online
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Website:
www.srmjrds.in
DOI:
10.4103/0976-433X.129055

0 to 23% for lingual nerve to 0.4-13.4% for inferior alveolar

nerve.[2] Of the several factors implicated in paresthesia,
some are avoidable and some are not. One factor that cannot
be avoided in a teaching institution is inexperience of the
surgeon. We therefore decided to develop a protocol based
on previous literature reports that would minimize the nerve
damage due to other avoidable factors.
The aim of our study was to assess the effectiveness of our
department protocol in preventing inferior alveolar and
lingual nerve paresthesia. The hypothesis was that this
protocol would reduce the incidence of paresthesia when
compared to previous literature reports.

MATERIALS AND METHODS

The patients included in this study were those who had been
referred to the Department of Maxillofacial Surgery of our
institution for removal of symptomatic third molars. Patients
with systemic diseases, and in whom the impacted teeth
were associated with pathological lesions, were excluded. All
patients were evaluated with an orthopantomogram prior to
the procedure.

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Singaram, et al.: Effectiveness of an evidence based protocol to evaluate sensory nerve paresthesia following third molar surgery

In all the patients, the surgical procedure was carried out by

post graduate students. All patients were informed that they
would be evaluated for study purposes and written consent
form was obtained. Local anesthesia was given using inferior
alveolar nerve block only after testing for positive aspiration.
The incision used was Wards or modified Wards incision.
A buccal mucoperiosteal flap was raised and retracted using
an Austins retractor. A lingual mucoperiosteal flap was
also raised and retracted using a Molts periosteal elevator.
Ostectomy was done using sterile handpieces and saline
irrigation. Tooth sectioning was carried out in all cases. After
retrieval of the tooth, wound closure was carried out using
3-0 silk sutures.

in one case (0.9%). Statistical analyses revealed that the

paresthesia was unrelated to age, the difficulty index,
redline and distance of root tips from the nerve canal
[Figures 1-5]. However, the incidence of paresthesia
appeared to be directly related to the duration of the
surgical procedure [Figure 6]. The results of the Chi-square
analysis are tabulated in Table 1.
In all cases, sensory nerve paresthesia was transient and
resolved within a period of 2 weeks. All patients with

A standardized data form was used to record the patients

age, sex, and Pedersons difficulty index based on Winters
and Pell and Gregory classifications. The distance between
the root apices and inferior alveolar canal, and the length of
the redline was also determined. After completion of the
procedure, the operating time was also noted.
Patients were followed up after 24 hours and 7 days. Patients
were specifically questioned about sensory changes in
the lower lip, chin and tongue on the treated side. If the
patients described any positive symptoms, testing of the
affected area was done using a sharp dental probe. Two point
discrimination, pin prick, touch and pressure tests were
carried out. Affected patients were placed on multivitamins
(Neurobion forte) and reviewed every week until recovery.

Figure 1: Influence of age on nerve paresthesia

Statistical analysis was done using Pearsons Chi-square test.

Each of the factors recorded on the data form was analyzed
for significance in relation to lingual and inferior alveolar
nerve paresthesia.

RESULTS
A total of 110 patients were included in the study out of
which 56 were male (50.1%) and 54 female (40.9%). The
age ranged from 18 to 67 years (mean 29.4 years). Most of
the patients were in the age group of 20-30. According to the
Pedersons index, 34 cases (30.9%) were classified as slightly
difficult, 52 (47.3%) as moderately difficult and 24 (21.8%)
as very difficult. The redline measurement was <5 mm in
61 cases (55.4%) and greater than 5 mm in 49 cases (44.5%).
In most of the cases, the mesial root tip was close to the
canal. The distance was positive in 14 cases (12.7%), null
in 19 cases (17.2%), close in 55 cases (50%) and well away
in 22 cases (20%). The distance of the distal root tip from
the canal was positive in eight cases (7.3%), null in 34 cases
(30.9%), close in 34 cases (30.9%) and well away in 34 cases
(30.9%). The duration of the surgical procedure ranged from
15 to 120 min, the average operating time being 43.7 min.
Postoperative inferior alveolar nerve paresthesia occurred
in five cases (4.5%) and lingual nerve paresthesia occurred

Figure 2: Influence of Pedersons Index on nerve paresthesia

Figure 3: Influence of Red Line on nerve paresthesia

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Singaram, et al.: Effectiveness of an evidence based protocol to evaluate sensory nerve paresthesia following third molar surgery

Table 1: Chi-square analysis of factors affecting nerve

paresthesia
Factor correlated
Age
Pedersons index
Red line
Distance of mesial root tip
from canal
Distance of distal root tip
from canal
Duration of procedure

Figure 4: Influence of distance between mesial root tip and

canal on nerve paresthesia

Figure 5: Influence of distance between distal root tip and canal

on nerve paresthesia

Figure 6: Influence of duration of procedure on nerve

paresthesia

paresthesia were followed up for 6 months. These patients

showed no discomfort in the region of nerve impairment
after resolution of numbness at 2 weeks.

DISCUSSION
Sensory nerve impairment is a serious complication of
third molar surgery. Whether temporary or permanent,
8

P value inferior
alveolar nerve
paresthesia
0.792
0.706
0.654
0.886

P value
lingual nerve
paresthesia
0.841
0.999
0.445
0.999

0.999

<0.05

<0.05

it is stressful for the patient and may form grounds

for litigation. [3] The etiology of nerve impairment is
multifactorial and several factors have been implicated in
previous studies. These include non-modifiable factors such
as degree of impaction,[4,5] relationship of the root apices
to the inferior alveolar canal,[6] and anatomical variations
in the lingual nerve course.[7,8] Modifiable factors include
experience of the operator, ostectomy, retraction of the
lingual flap and tooth sectioning.[9,10] The experience of the
operator has been a significant risk factor for both inferior
alveolar and lingual nerve paresthesias, especially permanent
sensory loss.[9,10] In a teaching institution, the inexperience of
the operator is a factor that cannot be avoided. It is therefore
essential to provide an evidence based protocol taking into
account all the other modifiable factors in order to reduce
the incidence of nerve paresthesia.
The non-modifiable factors which pose a risk of injury to
the inferior alveolar nerve and lingual nerve have been
described by several authors. Black[11] and Miura et al.[12] in
their respective studies showed that nerve injury was more
common among older patients. In the present study, although
very few patients presented in the older age group, this
factor was unrelated to nerve damage. The type and degree
of impaction has been related to nerve injuries. Wofford
and Miller stated that dysesthesia was more common in
complete bony and mesioangular impactions. Carmichael
and McGowan retrospectively analyzed 815 patients and
concluded that paresthesia was more common in completely
bony and horizontal impactions. Jerjes et al.[13] stated that
cases recorded as very difficult in the Pederson index were
95% more likely to develop permanent paresthesia. Leung and
Cheung[14] reviewed several prospective studies and stated that
unerupted teeth and distoangular impactions were associated
with high risk of lingual nerve paresthesia. In the present
study, however, none of these parameters were significantly
associated with inferior alveolar or lingual nerve paresthesia.
Modifiable factors such as ostectomy and tooth sectioning
are also thought to influence inferior alveolar nerve
injuries. Although tooth sectioning has not been
significant in reducing paresthesia in certain studies,[15]
it was theorized that tooth sectioning would reduce the

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Singaram, et al.: Effectiveness of an evidence based protocol to evaluate sensory nerve paresthesia following third molar surgery

amount of ostectomy performed and would also reduce

compression on the nerve canal by elevators. The method
of ostectomy appears to have an effect on inferior alveolar
nerve paresthesia. Rood et al.[16] compared bone removal
using a chisel and removal using surgical drills, and stated
that using a surgical drill produced a higher incidence of
permanent inferior alveolar nerve damage. However, the use
of chisel, especially in the lingual split technique, increases
the risk of lingual nerve paresthesia and hence was not
followed in the current protocol.
With regard to lingual nerve paresthesia, the most
controversial modifiable risk factor has been the raising
of a lingual flap. The lingual nerve has a wide degree of
anatomic variation, and has been found to lie above the
bony alveolar crest. The surgeon cannot therefore rely on
the lingual alveolar plate to protect the nerve and hence
some authors advocate intentionally raising the flap and
protecting the nerve using a retractor.[17-19].However, others
have argued that retracting the flap has resulted in an
increased incidence of paresthesia Pichler and Beirne[20]
analyzed eight such studies in a systematic review of the
literature. The authors concluded that the use of lingual
nerve retractor may associated with increased incidence
of temporary nerve damage but is neither protective nor
detrimental with regard to permanent nerve damage. It has
been recommended that with experience, raising the lingual
flap may be avoided. However, in the case of inexperienced
surgeons, it would be better to intentionally raise the flap and
protect the nerve by retraction to avoid inadvertent damage.
Therefore our current protocol is to raise a lingual flap and
protect the nerve, and this has resulted in an extremely low
incidence of paresthesia (0.9%) when compared to previous
studies. Appiah-Anane and Appiah-Anane[21] have reported
that the type of incision also determines the risk of lingual
nerve damage and most authors advocate a buccally directed
incision extending towards the external oblique ridge. In
the current study, Wards incision and a buccal approach
was used in all cases.
The only factor of significance in the current study was the
duration of the surgical procedure performed. In all cases
of paresthesia, the duration was above 90 min. This is in
agreement with the studies carried out in 1117 patients by
Valmaseda-Castelln et al. It is theorized that longer duration
would result in more postoperative swelling and hematoma
which, by compressing on the nerve, might have contributed
to temporary paresthesia.
In the current study, the incidence of inferior alveolar
nerve paresthesia was 4.5% and lingual nerve paresthesia
was 0.9%. In both cases, paresthesia was temporary and
complete recovered within 2 weeks. There was no incidence
of permanent paresthesia. In previous literature reports, the
incidence of inferior alveolar nerve paresthesia ranges from
0.4% to 13.4% (mean 4.5%) and lingual nerve paresthesia

ranges from 0 to 23% (mean 6.7%). Hence in following

the current protocol, the incidence of nerve paresthesia is
reduced even in the presence of several risk factors including
inexperience of the surgeons.

CONCLUSION
Even in the presence of non-modifiable risk factors for
paresthesia, it is possible to reduce the complication rates
to a minimum using an evidence based protocol. Using
a standard Wards incision, raising a lingual flap, use of
minimal ostectomy and tooth sectioning in all cases appears
to reduce the incidence of postoperative lingual and inferior
alveolar nerve paresthesias.

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How to cite this article: Singaram M, Krishnakumararaja VB,
Balasubramaniam S, Paneerselvam E, Poornima P, Gopi G. Sensory
nerve paresthesia following third molar surgery: Effectiveness of an
evidence based protocol. SRM J Res Dent Sci 2014;5:6-10.
Source of Support: Nil, Conflict of Interest: None declared

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