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Retrospective Review of Microsurgical Repair of 222 Lingual Nerve Injuries

Published:December 28, 2009DOI:https://doi.org/10.1016/j.joms.2009.09.111

      Purpose

      Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN.

      Materials and Methods

      A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved “useful sensory recovery” or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes.

      Results

      A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from “useful sensory function” to a “complete return of sensation”) was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to “useful sensory function”), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001).

      Conclusions

      Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.
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      References

        • Queral-Godoy E.
        • Figueiredo R.
        • Valmaseda-Castellón E.
        • et al.
        Frequency and evolution of lingual nerve lesions following lower third molar extraction.
        J Oral Maxillofac Surg. 2006; 64: 402
        • Schwartzman R.J.
        • Grothusen J.
        • Thomas R.
        • et al.
        Neuropathic central pain: Epidemiology, etiology and treatment options.
        Arch Neurol. 2001; 58: 1547
        • Zuniga J.R.
        Management of third molar-related nerve injuries: Observe or treat.
        Alpha Omegan. 2009; 102: 79
        • Blackburn C.W.
        • Bramley P.A.
        Lingual nerve damage associated with the removal of lower third molars.
        Br Dent J. 1989; 167: 103
        • Mason D.A.
        Lingual nerve damage following lower third molar surgery.
        Int J Oral Maxillofac Surg. 1988; 17: 290
        • Robert R.C.
        • Bacchetti P.
        • Pogrel M.A.
        Frequency of trigeminal nerve injuries following third molar removal.
        J Oral Maxillofac Surg. 2005; 63: 732
        • Hillerup S.
        • Stoltze K.
        Lingual nerve injury in third molar surgery I.
        Int J Oral Maxillofac Surg. 2007; 36: 884
        • Valmaseda-Castellón E.
        • Berini-Aytés L.
        • Gay-Escoda C.
        Lingual nerve damage after third molar surgical extraction.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 90: 567
        • Jacks S.C.
        • Zuniga J.R.
        • Turvey T.A.
        • et al.
        A retrospective analysis of lingual nerve sensory changes after bilateral mandibular sagittal split osteotomy.
        J Oral Maxillofac Surg. 1998; 56: 700
        • White R.P.
        • Peters P.B.
        • Costich E.R.
        • et al.
        Evaluation of sagittal split-ramus osteotomy in 17 patients.
        J Oral Surg. 1969; 27: 851
        • Guernsey L.H.
        • DeChamplain R.W.
        Sequellae and complication of the intraoral sagittal osteotomy of the mandibular rami.
        J Oral Surg. 1971; 32: 176
        • Cunningham S.J.
        • Crean S.J.
        • Hunt N.P.
        • et al.
        Preparation, perceptions, and problems: A long-term follow-up of orthognathic surgery.
        Int J Adult Orthognath Surg. 1996; 11: 41
        • Essick G.K.
        • Phillips C.
        • Turvey T.A.
        • et al.
        Facial altered sensation and sensory impairment after orthognathic surgery.
        Int J Oral Maxillofac Surg. 2007; 36: 577
        • Teerijoki-Oksa T.
        • Jaaskelainen S.
        • Forssell K.
        • et al.
        An evaluation of clinical and electrophysiologic tests in nerve injury diagnosis after mandibular sagittal split osteotomy.
        Int J Oral Maxillofac Surg. 2003; 32: 15
        • Essick G.K.
        • Austin S.
        • Phillips C.
        • et al.
        Short-term sensory impairment after orthognathic surgery.
        Oral Maxillofac Surg Clin North Am. 2001; 13: 295
        • Westermark A.
        • Englesson L.
        • Bongenhielm U.
        Neurosensory function after sagittal split osteotomy of the mandible: A comparison between subjective evaluation and objective assessment.
        Int J Adult Orthodon Orthognath Surg. 1999; 14: 268
        • Zuniga J.R.
        • Essick G.K.
        A contemporary approach to the clinical evaluation of trigeminal nerve injuries.
        Oral Maxillofac Surg Clin North Am. 1992; 4: 353
        • Susarla S.M.
        • Kaban L.B.
        • Donoff R.B.
        • et al.
        Does early repair of lingual nerve injuries improve functional sensory recovery?.
        J Oral Maxillofac Surg. 2007; 65: 1070
        • Robinson P.P.
        • Loescher A.R.
        • Yates J.M.
        • et al.
        Current management of damage to the inferior alveolar and lingual nerves as a result of removal of third molars.
        Br J Oral Maxillofac Surg. 2004; 42: 285
        • Zuniga J.R.
        • Tay A.B.
        Trigeminal nerve injury.
        in: Laskin D.M. AbuBaker A.O. Decision Making in Oral and Maxillofacial Surgery. Quintessence Publishing, Hanover Park, IL2007: 12-14
        • Meyer R.A.
        • Ruggiero S.I.
        Guidelines for the diagnosis and treatment of peripheral trigeminal nerve injuries.
        Oral Maxillofac Surg Clin North Am. 2001; 12: 383
        • Zuniga J.R.
        • Meyer R.A.
        • Gregg J.M.
        • et al.
        The accuracy of clinical neurosensory testing for nerve injury diagnosis.
        J Oral Maxillofac Surg. 1998; : 2
        • American Association of Oral and Maxillofacial Surgeons
        Parameters and pathways: Clinical practice guidelines for oral and maxillofacial surgery (AAOMS ParPath 01), version 3.0.
        J Oral Maxillofac Surg. 2001; 59: p1
        • Pogrel M.A.
        The results of microneurosurgery of the inferior alveolar and lingual nerve.
        J Oral Maxillofac Surg. 2002; 60: 485
        • Robinson P.P.
        • Loescher A.R.
        • Smith K.G.
        A prospective, quantitative study on the clinical outcome of lingual nerve repair.
        Br J Oral Maxillofac Surg. 2000; 38: 255
        • Robinson P.P.
        • Smith K.G.
        A study on the efficacy of late lingual nerve repair.
        Br J Oral Maxillofac Surg. 1996; 34: 96
        • Rutner T.W.
        • Ziccardi V.B.
        • Janal M.N.
        Long-term outcome assessment for lingual nerve microsurgery.
        J Oral Maxillofac Surg. 2005; 63: 1145
        • Renton T.
        Lingual nerve assessment and repair outcomes.
        Ann R Australas Coll Dent Surg. 2002; 16: 113
        • Scrivani S.J.
        • Moses M.
        • Donoff R.B.
        • et al.
        Taste perception after lingual nerve repair.
        J Oral Maxillofac Surg. 2000; 58: 3
        • Zuniga J.R.
        • Chen N.
        • Phillips C.L.
        Chemosensory and somatosensory regeneration after lingual nerve repair in humans.
        J Oral Maxillofac Surg. 1997; 55: 2
        • Lam N.P.
        • Donoff R.B.
        • Kaban L.B.
        • et al.
        Patient satisfaction after trigeminal nerve repair.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95: 538
        • Susarla S.M.
        • Lam N.P.
        • Donoff R.B.
        • et al.
        A comparison of patient satisfaction and objective assessment of neurosensory function after trigeminal nerve repair.
        J Oral Maxillofac Surg. 2005; 63: 1138
        • Wynn-Parry C.B.
        Brachial plexus injuries.
        Br J Hosp Med. 1984; 32 (134): 130
        • Mackinnon S.E.
        • Dellon A.L.
        Surgery of the Peripheral Nerve.
        Thieme Medical Publishers, New York1988
        • Meyer R.A.
        • Rath E.M.
        Sensory rehabilitation after trigeminal nerve injury or nerve repair.
        Oral Maxillofac Surg Clin North Am. 2001; 13: 365
        • Dodson T.B.
        • Kaban L.B.
        Recommendations for management of trigeminal nerve defects based on a critical appraisal of the literature.
        J Oral Maxillofac Surg. 1997; 55: 1380
        • Birch R.
        • Bonney G.
        • Wynn-Parry C.B.
        Surgical Disorders of the Peripheral Nerves.
        in: Churchill Livingstone, Philadelphia1988: 405-414
        • Alling C.C.
        • Schwartz E.
        • Campbell R.L.
        • et al.
        Algorithm for diagnostic assessment and surgical treatment of traumatic trigeminal neuropathies and neuralgias.
        Oral Maxillofac Surg Clin North Am. 1992; 4: 555
        • Ziccardi V.B.
        • Steinberg M.J.
        Timing of trigeminal nerve microsurgery: A review of the literature.
        J Oral Maxillofac Surg. 2007; 65: 1341
        • Seddon H.J.
        Three types of nerve injury.
        Brain. 1943; 66: 237
        • Seddon H.J.
        Nerve lesions complicating certain closed bone injuries.
        JAMA. 1947; 135: 691
        • Meyer R.A.
        Applications of microneurosurgery to the repair of trigeminal nerve injuries.
        Oral Maxillofac Surg Clin North Am. 1992; 4: 405
        • Gregg J.M.
        Studies of traumatic neuralgias in the maxillofacial region: Symptom complexes and responses to microsurgery.
        J Oral Maxillofac Surg. 1990; 48: 135
        • Gregg J.M.
        Studies of traumatic neuralgias in the maxillofacial region: Surgical pathology and neural mechanisms.
        J Oral Maxillofac Surg. 1990; 48: 228
        • Sunderland S.
        Observations on the course of recovery and late end results in a series of cases of peripheral nerve suture.
        Aust N Z J Surg. 1949; 18: 264
        • Verdu E.
        • Ceballos D.
        • Vilches J.J.
        • et al.
        Influence of aging on peripheral nerve function and regeneration.
        J Peripher Nerv Syst. 2000; 5: 191
        • Pola R.
        • Aprahamian T.R.
        • Bosch-Marce M.
        • et al.
        Age-dependent VEGF expression and intraneural neovascularization during regeneration of peripheral nerves.
        Neurobiol Aging. 2004; 25: 1361
        • Wynn-Parry C.B.
        • Salter R.M.
        Sensory re-education of median nerve lesions.
        Br J Hand Surg. 1976; 8: 250
        • Gregg J.M.
        Surgical management of lingual nerve injuries.
        Oral Maxillofac Surg Clin North Am. 1992; 4: 417
        • Meyer R.A.
        Evaluation and management of neurologic complications.
        in: Kaban L.B. Pogrel M.A. Perrott D.H. Complications in Oral and Maxillofacial Surgery. WB Saunders, Philadelphia1997: 69-88