A 21 year retrospective study of reports of paresthesia following local anesthetic administration
Nerve injuries following nerve blocking in the pterygomandibular space
The etiology of altered sensation in the inferior alveolar, lingual, and mental nerves as a result of dental treatment
Lingual nerve paresthesia following third molar surgery: a retrospective clinical study.
Dysesthesia and anesthesia of the mandibular nerve following dental treatment
Permanent nerve involvement resulting from inferior alveolar nerve blocks.
Potent analgesic effects of GDNF in neuropathic pain states
Burning mouth syndrome (BMS): controlled open trial of the efficacy of alpha-lipoic acid (thioctic acid) on symptomatology
Evaluation of precautions adopted by dental surgeon using local anaesthesia
The use of autogenous vein grafts for inferior alveolar and lingual nerve reconstruction
Evidence-based means of avoiding Lingual Nerve Injury following Mandibular Third Molar Extractions
Braz J Oral Sci. April/June 2003 - Vol. 2 - Number 5
George W. Bernard DDS, Ph D
Victor Mintz DDS, MS
Division of Oral Biology and Medicine
University of California, Los Angeles School of Dentistry
Received for publication: April 8, 2003
Accepted: May 20, 2003
Severe damage or severance of the lingual nerve can result in permanent numbness, loss of taste
and dysthesia of the anterior two-thirds of the tongue on the side of the mandibular third molar extraction, causing
a lifetime of distress. During third molar extractions the incidence of injury and severance to the lingual nerve is
far too prevalent. According to Kurt Thoma’s textbook of Oral Surgery, third edition, injury to the lingual nerve is
invariably caused by negligence.
Thoma states that in ordinary cases any injury to the lingual nerve is gross negligence1. In recent years many
articles have been written to confirm the reason for this. Because there is enormous variation in the pathway of the
lingual nerve, especially in the third molar area 2,3,4,5, oral surgeons from Thoma forward developed techniques for
3rd molar extractions which limited extractions to a buccal approach, thereby giving a wide surgical berth to most
variations of the lingual nerve. These variations are listed as running from the crest of the lingual bone to below
the floor of the mouth. Sometimes one of the variations is the lingual nerve traversing the retromolar pad area2,4.
Staying away from the lingual bone during extractions, and the retromolar pad for incisions will keep the surgeon
away from the multiple pathways the lingual nerve might take. If the dentist is cognizant of the lingual nerve
ariations, they will then know where to design the boundaries of the surgical field. If for some reason the dentist
has no choice but to involve an area where the lingual nerve might be, then it is incumbent that the nerve be
carefully dissected, identified and gently retracted to protect its integrity.
If this is not done, various degrees of parethesia, dysesthesia and anesthesia may result in the anterior two-thirds
of the tongue, floor of the mouth and lingual gingiva. Severance of the lingual nerve will include a variable loss of
taste because of the involvement of the chorda tympani nerve, which runs within the lingual nerve sheath7. Lingual
nerve injury occurs by direct compression, incision or excision during third molar removal, periodontal surgery,
tumor removal and also in cases of trauma whenever procedures are performed in the retromolar area. Alling8 lists the
following reasons for lingual nerve damage by quoting Mozsary and Middleton9, poor flap design, uncontrolled
instrumentation or fracture of the lingual Plate. Poor flap design is an admission of lack of knowledge of anatomy of
the surgical area. Uncontrolled instrumentation demonstrates a lack of care and caution in performing the surgery and
fracture of the lingual plate shows an abandonment of knowledge of proper technique. During the seventies and
eighties some articles were written and published by oral surgeons, trying to justify lingual nerve injuries
resulting from the removal of impacted third molars. One author distributed a questionnaire to oral surgeons
throughout the country, requesting reasons for how the lingual nerve could be injured. He got an enormous response in
terms of numbers and eighteen causes for the damage, but no one described or explained how or why anesthesia
occurred, and of course no one admitted to negligence5. Other articles reported, paradoxically, that the anatomical
variations in the course of the lingual nerve justified the injuries.
Several attempts were reported in regard to stretching and compression of the nerve while retracting the lingual
flap. Some articles assumed a trauma to the lingual nerve as a result of the anesthetic injections even the toxicity
of the Lidocaine as causes of damage to the nerve, but there were no substantiation of these claims by any reliable
scientific studies10. There have been numerous articles that deny negligence based upon the assumed damage caused by
penetration through or into the nerve by the injection needle. But in the Journal of the American Dental Association,
Anthony Pogrel wrote Direct trauma from the needle seems unlikely because it is known that most cases of trauma
resulting from needle contact resolve spontaneously. It is difficult to envision how needle trauma can damage the
whole nerve10. Kraft and Hickel11 reported that they gave 12,104 mandibular block injections without performing
surgery and found there was not one case of complete permanent anesthesia. Of these cases, there were 18 cases of
temporary anesthesia of the lingual nerve, indicating penetration into the nerve sheath with complete healing
afterward. This was direct evidence that piercing the lingual nerve did not sever it11. They wrote block anesthesia
alone does not have a decisive impact on the incidence of lingual sensory disturbance in surgical third molar
removal. Because the buccal approach for extracting the lower 3rd molar is the method of choice in the United States,
current Oral Surgery textbooks and the guidelines of the American Association of Oral and maxillofacial Surgeons
(AAOMS) favor this procedure. The articles, which report on the various reasons as to how the lingual nerve can be
inadvertently damaged, are attempts to cover up negligence. None of those reasons are legitimate in terms of
justifying the damage that could occur during the operation, and are not within the standard of care. Technology and
instrumentation today has made the surgery significantly simpler than it was four decades ago when Thoma wrote his
book. Dental surgeons have education, training and experience. They have learned anatomy and other pertinent basic
sciences, and should be fully conscious of the structures that are encountered in doing any procedure. No surgeon
should ever attempt to perform an operation without the capability of doing it properly and successfully completing
the task. Because current oral surgery textbooks and discourse in university classrooms favor the buccal approach in
the removal of impacted third molars, the external oblique ridge is used as a marker for the incision going distally
and buccally, and begins at the distobuccal angle of the second molar, bearing in mind that the ramus of the mandible
flares laterally and posteriorly. This portion of the incision is continuous with the vertical buccal release
incision alongside the first or second molar. This usually allows the surgeon to gain adequate access to the lower
wisdom teeth, impacted or not, and carefully manage the lingual flap which might include the retromolar pad without
endangering the lingual nerve. If a straight line is drawn through the central fossae of the premolars and the
molars, and it is extended through the retromolar pad, this line would end on the lingual or medial surface of the
ramus, almost exactly where the lingual nerve usually comes down between the medial surface of the mandible and the
hyoglossus muscle on its way anteriorly and inferiorly through the lingual mucosa to the lateral border of the sub-
mandibular gland and the floor of the mouth.
An incision directed in any of these areas could very likely cause a severance of the lingual nerve. Obviously, the
lingual flap has to be carefully retracted with a safe type of retractor when it is necessary to remove occlusal
bone covering an impacted mandibular third molar in order to protect the flap, remove bone, section the tooth, and
elevate sectioned portions of the tooth. Uncontrolled instrumentation is negligence and is one of the causes of
damaging or severing the lingual nerve. Bone removal and tooth sectioning with a relatively high speed drill is
another cause of nerve damage and severance, especially when the lingual bone is pierced or cut. Again, this can be
avoided with careful, adequate, deliberate retraction, controlled instrumentation and direct vision of the surgical
In summary, with the buccal approach under direct vision, proper incision, careful bone removal, management and
protection of the flap during drilling, and elevation of the tooth structure, the lingual nerve can be preserved
during the surgery of mandibular third molars. In addition, with the proper incision, there is properly positioned
tissue to permit safe placement of the sutures. Following the accepted technique of the buccal approach, using the
external oblique ridge as a marker and making a buccal incision with a full mucoperiostal flap, one can gain
sufficient access to the third molar, if it is partially or fully impacted. Variations of the course of the lingual
nerve made clear by anatomical dissections indicate that it occasionally passes through the retromolar pad2,7. This
reinforces the obligatory use of the buccal incision. A new major surgical problem occurs when it is necessary to
remove bone covering the distocclusal portion of the tooth before removing the tooth. This requires great care in
gaining access to the area. The lingual flap has to be retracted to expose the bone to be removed by drilling or
chisel. It is of the utmost importance that this lingual flap be protected at all times by means of a properly placed
and designed retractor so that the lingual flap is not damaged or excessively compressed because this is an area
where the lingual nervemight be encountered. Pichler and Beirne report that the Various types of lingual retractors,
such as Howarth’s, Ward’s, Meade’s, Hovell’s and Rowe’s retractors have been used for this purpose. During Third
Molar extractions recently, attention has been focused on the safety of lingual flap retractors, with some studies
particularly critical of the narrowness of the Howarth’s periosteal elevator 12,13. Other articles have also shown
that though lingual nerve retraction during third molar removal may cause transient damage, it is not associated with
permanent damage, and it has been suggested that lingual nerve retraction should be used in the removal of third
molars when necessary. Because a periosteal elevator may not be a broad enough retractor to totally protect the
nerve, special retractors have been developed for this purpose10,14,15. Greenwood et al.16 showed that a broader
lingual retractor as compared to a Howarth’s elevator was much less likely to be associated with sensory loss. Most
oral surgeons and experienced dentists never sever the lingual nerve. They do not because they follow the rules of
proper extraction of 3rd molars, and therefore always practice within the standard of care.
1. Thoma KH. Oral Surgery. 3rd ed. Saint Louis: Mosby; 1969.
2. Keisselbach JE, Chamberlain JG. Clinical and anatomic observations on the relationship of the lingual nerve to the
mandibular third molar region. J Oral Maxillofac Surg. 1984;42: 565-7.
3. Pogrel MA, Renaut A, Schmitt B. Ammar,. Relationship of the lingual nerve to the mandibular third molar region.
J Oral Maxillofac Surg. 1997; 53: 134-7.
4. Behnia H, Kheradvar A, Shahrokhi M. An anatomic study of the lingual nerve in the third molar region.
J Oral Maxillofac Surg. 2000; 58: 649-51.
5. Miloro M, Halkias LE, Sloane HW, Chakeres DW. Assessment of the lingual nerve in the third molar region using
magnetic resonance imaging. J Oral Maxillofac Surg. 1997; 55: 134-7.
6. Peterson L, Ellie E, Hupp J, Tucker M. Contemporary oral and maxillofacial surgery.
4th ed. Saint Louis: Mosby; 2003.
7. Pogrel MA, Kaban LB. Injuries to the interior alveolar and lingual nerves. Calif Dent J. 1993; 21: 50-4.
8. Alling CC. Dysthesia of the lingual and inferior alveolar nerves following third molar surgery.
J Oral Surg. 1973; 31: 918-20.
9. Mozsary PG, Middleton RA. Microsurgical reconstruction of the lingual nerve.
J Oral Maxillofac Surg. 1984 ;42: 415-20.
10.Pogrel MA, Thambi SRI. Permanent nerve damage resulting from inferior alveolar nerve blocks.
J Am Dent Assoc. 2000;131: 901-7.
11.Kraft TC, Hickel R. Clinical investigation into the incidence of direct damage to the lingual nerve caused by
local anesthesia. J Craniomaxillofac Surg. 1994; 22: 294-6.
12.To EW, Chan FF. Lingual nerve retractor. Br J Oral Maxillofac Surg. 1994; 32: 125-6.
13.Blackburn CW, Bramley PA. Lingual nerve damage associated with the removal of third molars.
Br Dent J. 1989; 167: 103-7.
14.Browne WG. Lingual flap retractor for surgery in third molar area. Br J Oral Surg. 1982; 20: 151-2.
15. Dean Medical Instruments, Inc. 15502 Commerce Lane, Huntington Beach CA, 92649, USA.
16. Greenwood M, Langton SG, Rood JP. A combination of broad and narrow retractors for lingual nerve protection
during lower third molar surgery. Br Oral Maxillofac Surg. 1996; 34: 143-57.
The course of the lingual nerve can be seen in the following illustrations:
From "Anatomy, A Regional Atlas of the Human Body", Carmine D. Clemente, printed by Lea & Febiger, 1975;
Courtesy: Urban & Fischer Verlag
The Infratemporal Region and the Branches of the Mandibular Nerve
The Infratemporal Region and the Maxillary Artery
Nerves of the Nasal and Oral Cavities and the Otic Ganglion