J Oral Maxillofac Surg 53:1178-1181, 1995

The Relationship of the Lingual Nerve to the Mandibular Third Molar Region:
An Anatomic
ANDREW

Study
FRCS,* SCHMIDT, DDS,*

M. ANTHONY POGREL, MB, CHB, BDS, FDSRCS, RENAUT, MB, BS, BDS, FDSRCS, FRCSJ BRIAN AND AWNIE AMMAR, BS

Purpose: This study evaluated the relationship of the mandibular third molar to the lingual nerve. Materials and Methods: An anatomic dissection of the lingual nerve in the third molar region was done on 20 cadavers (40 sides). Results: The position of the nerve on one side bore no statistical relationship to the position of the nerve on the opposite side. The position of the lingual nerve was variable in both the sagittal and coronal planes. In two specimens the nerve lay superior to the lingual plate and in another the superior surface of the nerve was level with the crest of the lingual plate. Conc/usion: These findings have implications for the avoidance of lingual nerve damage during surgery in the third molar and retromolar region of the mandible.

The proximity of the lingual nerve to the third molar region of the mandible is an important consideration when performing surgery in this area. Injury can occur by direct excision during tumor removal as well as following trauma, third molar removal, and periodontal procedures. The nerve is particularly at risk during those procedures performed in the retromolar region. A 0.6% to 2.0% incidence of lingual nerve injury has been reported following third molar extraction. In addition to causing loss of sensation in the anterior two thirds of the tongue on the affected side, taste can be affected because the chorda tympani nerve runs within the lingual nerve sheath. An accurate knowledge of the position of the lingual nerve in the third molar area therefore is necessary when performing surgery in this region.
Received from the University of California at San Francisco, San Francisco, CA. * Professor and Chairman, Department of Oral Maxillofacial Surgery. t Chief Resident, Department of Oral Maxillofacial Surgery. $ Resident, Department of Oral Maxillofacial Surgery. $ Dental Student. Address correspondence and reprint requests to Dr Pogrel: Department of Oral and Maxillofacial Surgery, University of California at San Francisco, School of Dentistry, 521 Parnassus Ave, C-522, San Francisco, CA 94143-0440. 0 1995 American 0278-2391/95/531 Association of Oral and Maxillofacial O-001 0$3.00/O Surgeons

Kiesselbach and Chamberlain6 have described the nerve as lying lingual and inferior to the crest of the lingual plate of the mandible with a mean position of 2.28 mm (kO.9) below the crest and 0.58 mm (kO.9) medial to the crest. However, in their cadaver and clinical studies they also reported that in 17.6% of cases, the lingual nerve lay at or above the crest of the lingual plate of the mandible and could lie in the retromolar tissues and therefore be at increased risk during surgery in this area. The present study attempted to describe the precise anatomic relationship of the nerve to the mandibular third molar region in three dimensions while using a reproducible landmark on the mandible. One side of the mandible was compared with the other, and the presence or absence of teeth was noted.
Materials and Methods

Twenty cadaveric heads were bisected sagittally. The lingual nerve on each side was dissected via a 4cm to 5cm incision made over the lingual plate of the mandible. The nerve was identified from the region of the lingual of the mandible to the point where it leaves the mandible to traverse the floor of the mouth to reach the tongue. The nerve was identified, but not dissected free, so as not to disturb its relationships. The point
1178

POGREL

ET AL

1179 LINGUAL CORTEX t

8.32mm 1

on the internal oblique ridge of the mandible where the ridge makes an identifiable change in direction from vertical to horizontal was taken as the position of the retromolar pad for identification purposes and was defined as point A. The following measurements were made: (1) the closest distance of the nerve (defined as point B) to point A in any sagittal direction (Fig l), and (2) the vertical distance of point A from the nerve (point C; Fig 1). A point of divergence of the nerve from the lingual plate of bone, as seen in the coronal plane as it crosses the floor of the mouth to enter the tongue, was identified as Point D and the distance of point B from point D (Fig 1) was recorded. The closest point of the nerve to the lingual plate of the mandible was also noted and measured. All distances were measured to the most superior aspect of the nerve. The presence or absence of a third molar tooth was also noted. The nerve diameter in the retromolar region was measured with calipers. The position of the nerve as one side was compared with the position on the other side using Pearsons Correlation Coefficient.
Results

BUCCAL CORTEX

3.45mm

LINGUAL NERVE

FIGURE 2. Diagram showing the most frequent relationship of the lingual nerve to the lingual side of the mandible in the retromolar area. The nerve lies on the superior attachment of the mylohyoid muscle. The mean vertical distance from the crest of the lingual plate is 8.32 mm and the mean horizontal distance is 3.45 mm.

The mean distance of point A to point B was 4.45 mm (SD = 1.48 mm). In all cases, point B was posterior to point A. The mean vertical distance (AC) was 8.32 mm (SD = 4.05 mm). In two cases it was noted that point B was superior to point A and in one case it was level with the crest of the lingual plate. The mean sagittal distance of the lingual nerve before divergence from the lingual plate of the mandible (BD) was 27.7 mm (SD = 5.69 mm). Teeth were present in the third molar region in seven

sides, but did not have any statistical effect on the nerve position. The closest distance of the nerve to the mandible was a mean of 3.45 mm, with a range of 1.0 to 7.0 mm (SD = 1.48 mm). The average nerve diameter was 3.62 mm (range, 2.5 to 4.5 mm; SD = 1.00 mm). Pearsons Correlation Coefficient showed a negative correlation between the position of the nerve on one side and its position on the other side. The mean location of the nerve relative to the lingual plate of the mandible is shown in Figure 2. Figure 3 shows a very low-lying lingual nerve and Figure 4 shows the nerve running high in the retromolar tissues.
Discussion

This study shows that the lingual nerve has a close relationship to the lingual plate of the mandible in the mandibular molar and retromolar area for a mean distance of more than 27 mm. It is thus sufficiently

FIGURE 1. Reference points used for studying the relationship of the lingual nerve to the retromolar region in the sagittal plane. Point A is the anterior limit of the retromolar pad. Point B is the closest position of the lingual nerve to Point A, and point c is the vertical distance of the nerve from point A. Point D represents the point at which the nerve diverges from the side of the mandible to reach the tongue.

FIGURE 3. Cadaver dissection showing a low lingual nerve (white arrow) located 12 mm inferior to the retromolar tissues. Black WYOW shows incisor teeth for orientation.

1180

THE

LINGUAL

NERVE

AND

THE

MANDIBULAR

THIRD

MOLAR

FIGURE! 4. Cadaver dissection showing a high lingua1 nerve (white arrow) running superior to the crest of the lingual plate in intimate relationship with the retromolar tissues (black arrow).

close to the lingual plate of the mandible over a distance of nearly 3 cm to be at risk in any surgery performed on the lingual side of the mandible. When the vertical relationship of the nerve is considered in relationship to the lingual plate of the mandible in the region of the retromolar pad, it is evident that in most cases the nerve lies inferior to the crest of the lingual plate and is therefore partially protected by it. Its mean distance inferior to the crest of the lingual plate was over 8 mm when measured from the superior aspect of the lingual plate to the upper border of the nerve. In one case, however, the nerve was level with the crest of the lingual plate, and in two cases the nerve lay superior to the lingual plate. It can be envisaged that when the nerve is in these positions, it could be injured during any flap-raising procedure in the retromolar area and, in cases where the nerve was clearly superior to the crest of the lingual plate, damage could be envisaged even when using a technique not infringing on the lingual cortex with cutting instruments. The finding of the nerve being level with, or superior to, the lingual plate in 15% of cases is in broad agreement with the figures of Kiesselbach and Chamberlain. There was no statistical relationship between the position of a nerve on one side and its position on the opposing side. As an example, in the specimen where the nerve was lying level with the crest of the lingual plate on one side, it was lying over 11 mm inferior to the crest on the contralateral side. Thus, finding the nerve in a normal or abnormal position on one side does not predict the position on the contralateral side. In this study, the presence or absence of teeth had no statistical relationship to the position of the nerve and its relationship to the crest of the lingual plate or the retromolar trigone. Conceptually, it would be thought that loss of the posterior teeth would result in alveolar resorption causing some loss of the superior border of the lingual plate of the mandible. This would alter the relationship of the lingual nerve to the lingual

plate and make it more likely for it to be situated level or superior to the lingual crest. This did not appear to be true in this study. It could be due to the small number of specimens involved, but also may be because there is little resorption of the lingual plate in the retromolar trigone region when the teeth are lost, or because when the superior border of the lingual plate does resorb from the lingual nerve it moves with it in an inferior direction maintaining the same relationship. The horizontal distance of the lingual nerve from the lingual plate of the mandible was greater in this study than in previous studies. The mean distance of the lateral aspect of the nerve to the lingual plate of the mandible was 3.45 mm, which contrasts with 0.58 mm reported by Kieselbach and Chamberlain.6 Information about the state of the dentition of the cadavers dissected by Kieselbach and Chamberlain6 is not available, but it is possible that since most of the cadavers in the present study were edentulous, the mylohyoid ridge and muscle tended to lie more superiorly and, because the nerve would be lying on the mylohyoid muscle in this region for much of its course, the greater distance in the present study may be due to the thickness of the muscle itself. In a dentate model, it is reasonable to assume that the mylohyoid muscle would be lower in the mouth and that the nerve would be closer to the lingual plate, particularly in those cases where the nerve was located more superiorly and therefore above the mylohyoid muscle. When one analyzes the small number of dentate cases in the present study, however, there is no significant difference in the lateral distance of the nerve from the lingual plate. The variable position of the nerve is an obvious factor in the etiology of lingual nerve damage and emphasizes the problem of protecting the nerve during hard and soft tissue surgery7 in the third molar region. Rood* showed that lingual nerve retraction during third molar surgery may be associated with a transient lingual nerve paresthesia in 13% of patients. However, in Roods study, there were no cases of permanent lingual nerve damage, whereas the control group without the use of lingual retractors showed a 3.2% incidence of lingual nerve damage, 2% of which was permanent. All cases of permanent lingual nerve damage were associated with the use of a bur, which may perforate the lingual plate. 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 routinely in the removal of third molars. However, a periosteal elevator may not be a broad enough retractor to totally protect the nerve. and special lingual flap retractors have been developed for this purpose. The findings from the current study, which show the variable position of the nerve, suggest that unless adequate lingual

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E. KISSELBACH

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5. Alling CC: Dysesthesia of the lingual and inferior alveolar nerves following third molar surgery. J Oral Maxillofac Surg 441454, 1986 6. Kieselbach JE, Chamberlain JE: Clinical and anatomic observatory on the relationship of the lingual nerve to the mandibular third molar. J Oral Maxillofac Surg 42:565, 1984 7. Reinhart TC: Anatomic variation of the position of the lingual nerve. J Periodontol 61:305, 1990 8. Rood JP: Permanent damage to inferior alveolar and lingual nerves during removal of impacted mandibular third molars: Comparison of two methods of bone removal. Br Dent J 172:108, 1992 9. Blackburn CW, Bramley PA: Lingual nerve damage associated with the removal of lower third molars. Br Dent J 167: 103, 1989 10. Mason D: To retract or not retract. Br Dent J 168:94, 1989 11. Browne WG: Lingual flap retractor for surgery in third molar area. Br J Oral Surg 20:151, 1982

retraction is used for any surgery impinging on the lingual tissues, it may continue to suffer permanent damage.
References
1. Rud J: The split bone technique for removal of impacted mandibular third molars. J Oral Surg 28:416, 1970 2. van Go01 AV, ten Bosch JJ, Boering G: Clinical consequences of complaints and complications after removal of the mandibular third molar. Int J Oral Surg 6:29, 1977 3. Bruce RA, Frederickson GC, Small GS: Age of patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc 101:240, 1980 4. Schwartz LJ: Lingual anesthesia following mandibular odontectomy. J Oral Surg 31:918, 1973

J Oral Maxillofac 53:1181, 1995

Surg

Discussion
The Relationship of the Lingual Nerve Mandibular Third Molar Region: An Anatomic Study John E. Kiesselbach,
Woodland, CA

to the

DDS

This study shows that one patient in seven will have either their left or right lingual nerve located above the lingual plate in the third molar region. This percentage confirms my own experience from cadaver dissections. Although the nerve may be very close to the third molar at the time of surgery, it is not always visable because the periosteum or follicle may be located between the tooth and the nerve. This study used point A to represent the retromolar pad and point B to represent the closest distance, in a saggital plane, of the nerve to the retromolar pad. It is significant that point B was always posterior to point A and that in three cases it was level with or above point A. This means that an incision directed posteriorly, or distal to the third molar, could result in transection of the nerve and loss of taste and sensation to one side of the tongue. In this study the proximity of the nerve to the lingual plate was variable, not only from one patient to another but also from the left side to the right side of each patient. The results indicate that the nerve may be in close proximity to the lingual plate for a distance of 27 mm anterior to point B. The dissections also found the nerve to be as close as 1 mm to the lingual plate, which is essentially the thickness of the periosteum. To avoid injury to the lingual nerve it is helpful to understand that its position in the third molar region is influenced by the regional anatomy as well as genetics. The position of the nerve in the third molar area may be related to variations in the shape of the alveolar ridge as well as to the distance of the ramus of the mandible from the third molar. The medial or lingual extension of the alveolar ridge in the third molar region also varies among individuals and will affect the course of the lingual nerve. In some cases where the alveolar ridge and third molar are positioned medially relative to the ramus, the nerve may be in close contact with

the periosteum covering the distal or medial side of the third molar socket. The distance of the ramus from the third molar is variable anteroposteriorly as well as mediolaterally and this may also affect the course of the lingual nerve as it exits the plexygomandibular space and courses past the third molar toward the tongue.3 It seems intuitive that if the vertical ramus is located very close to, or on top of, the third molar, the lingual nerve may be very close to the third molar socket. Clinically the nerve can sometimes be palpated or even seen through the thin mucosa of the posterior lingual sulcus after it passes the third molar.4 It is also important to note that the second and third molars may be tilted lingually. If the third molar is tipped lingually the lingual plate may drop apically to a point where the nerve may be vulnerable to a sharp instrument used while extracting a tooth, performing an osteotomy, or any other proceedure. Further study of the lingual nerve in the third molar region should be persued. Another cadaver study could measure the proximity of the nerve to the third molar by making coronal plane sections of frozen specimens and measuring the distance of the lingual nerve from the lingual plate. Similar in vivo measurements could be done with magnetic resonance imaging (MRI). Reformating the MRI would allow the nerve to be viewed in any plane. This study was well done and confirms the fact that the lingual nerve is found at or above the level of the lingual plate of bone in the third molar region in 15% of patients. It is also clinically important to know that the nerve may be within 1 mm of the bone (essentially the thickness of the periosteum) on the lingual or distal side of the third molar. References
1. Kiesselbach JE, Chamberlain JE: Clinical and anatomic observations on the relationship of the lingual nerve to the mandibular third molar. J Oral Maxillofac Surg 42:565. 1984 2. Sicher H, Dubrul E: Oral Anatomy (ed 6). St Louis, MO, Mosby, 1975, pp 390-475 3. Alling RD, Alling CC: Impacted Teeth. Philadelphia, PA, Saunders, 1993, pp 159-160. 4. Merrill RG: Dent Clin North Am 23:473, 1979