British Journal of Oral and Maxillofacial Surgery (1999) 37, 134136

1999 The British Association of Oral and Maxillofacial Surgeons

BRITISH JOURNAL OF ORAL

& M A X I L L O FA C I A L S U R G E RY

Sensory disorders after separation of the nasopalatine nerve during removal

of palatal displaced canines: prospective investigation
A. Filippi, Y. Pohl, U. Tekin
Department of Oral Surgery, University of Gieen, Germany
SUMMARY. During a prospective study after separation of the nasopalatine nerve at the foramen incisivum during
exposure or removal of impacted and palatal displaced maxillary canines, 59 patients were examined neurologically
for 4 weeks postoperatively over an investigation period of 18 months. During the first week after the operation,
subjective as well as objective sensory disorders were found in all of the patients, but after 4 weeks at the most no
neurological deficit could be detected in any patient.

INTRODUCTION
Apart from the third molars, the maxillary canines are
most often prevented from assuming their correct
alignment in the row of teeth. The prime cause of this
is lack of space, because maxillary canines erupt after
the adjacent teeth. Depending on age and the particular orthodontic state, the methods of treatment can
entail exposure and orthodontic alignment, autologous tooth transposition1 or removal by osteotomy.
As most of the maxillary canines are displaced
palatally,2,4 they must be approached from that direction. When only the displaced tooth is exposed and a
ligature is used, and provided that the displaced tooth
is both palpable and visible, excision of the oral
mucosa around the crown of the canine tooth5 or an
incision to obtain a roll flap6,7 are indicated. However,
if it cannot be palpated, and in all tooth extractions
requiring osteotomy, a more generous incision must
be made to ensure good general viewing during the
operation.
Different types of incision are recommended for
removal of teeth from the palate (Fig. 1). One possible
way to classify these is to differentiate between paramarginal types of incision3,810 and incisions of the gingival margin.1113 Another way is to divide the types of
incisions into those that are as gentle as possible to the
vascular nerve bundle at the foramen incisivum either
by cutting round it or by avoiding it4,1416 and those that
sever these structures.10,11,17 The present investigation
will shed some light on the incidence of postoperative
sensory alterations in the mucous membrane of the
mouth in the region of the anterior teeth after the
nasopalatine nerve has been severed peroperatively.

Fig. 1 Diagram of palatal types of incision for the surgical

removal of the impacted and displaced tooth 13. 1 = incision of
the gingival margin, 2 = paramarginal incision, 3 = paramarginal
incision with a median-relieving incision, avoiding the foramen
incisivum.

removing the tooth, the mucoperiosteal flap is

replaced and fixed by interdental sutures. A prepared
oral guard is then inserted and kept in by the patient
for about a week until the stitches can be removed.
During the investigation period of 18 months (July
1995December 1996) the vascular nerve bundle in
the region of the foramen incisivum was severed with
a scalpel in the course of removal or exposure of
canines in 59 patients. After the operation they were
invited to attend follow-up examinations scheduled
after 24 h and 1, 2 and 4 weeks. The following variables were recorded: patients age at the time of the
operation, time since the operation, subjective presence of adverse sensations, and objective findings of
sensory disorders in the nerve supply to the nasopalatine nerve by using the pointed/blunt discrimination

PATIENTS AND METHODS

We treat impacted or displaced teeth, which are clinically neither visible nor palpable, by cleanly severing
the vascular nerve bundle at the foramen incisivum
after incising the palate at the gingival margin. After
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Sensory disorders following separation of the nasopalatine nerve

method (neurological test using a pointed and a blunt

instrument) and comparing each time with the palatal
mucous membrane in the region of the lateral teeth.

RESULTS
In the patients examined after the operation, tooth 13
was treated by severing the nasopalatine nerve in 26
cases and tooth 23 in 33 cases. Twenty-five of the
patients were male and 34 female. At the time of the
operation the patients mean (SD) age was 23 (15)
years (range 948, median 16).
At the follow-up examination 1 week postoperatively all patients had objective sensory disorders. The
area of the anaesthetized zones extended from the
ventral plica palatina transversa into the interdental
papillae of the anterior teeth. There was no sensation
of numbness in the tips of the papillae or in the
mucous membrane of the palate dorsally from the
first plica palatina transversa. The subjective sensory
disorders recorded at the same time indicated alterations in keeping with a slight swelling in 52 of the
cases. Seven patients did not notice any sensory
changes. After 2 weeks, 31 patients still had objective
sensory disorders. By 4 weeks no subjective or objective sensory disorders were diagnosed in any of the
patients.

DISCUSSION
Some types of incisions were favoured to avoid potential sensory disorders of the nasopalatine nerve by
cutting around the papilla incisiva or avoiding it. The
greatest disadvantage of these types of incisions is the
general lack of visibility within the operating area.
Usually there is contact between the crown of the
canine and the root of a functioning adjacent tooth,
primarily the lateral incisor. With a paramarginal type
of incision or cutting around the papilla incisiva, or
both, the crown of the tooth that has to be removed is
in these cases completely or partly covered by retained
mucous membrane, and removal of the tooth under
good viewing conditions is not guaranteed. It has
therefore been recommended that, in the case of
crowding between a displaced tooth and the roots of
teeth that are properly positioned, an incision of the
gingival margin or a modified variation which is gentle to the papilla,3 offers better viewing and so should
be used.11,12,17 Potential contacts between the canine
and the roots of properly positioned teeth can be recognized by direct viewing. Damage of adjacent periodontia during removal of the bone is then less likely.
There is no bleeding worth mentioning from the
severed periodontal vessels at the foramen incisivum.
In this prospective study no subjective or objective
sensory disorders were found more than 4 weeks after
operation in any of the patients. Any concerns about
postoperative neurological deficiencies have already
been investigated by us, retrospectively, over the last few
years.18 Neurological deficiencies of the nasopalatine

135

nerve were evident in only a few isolated elderly

patients, so that reduced regenerative ability has to be
assumed in these cases. These anaesthetic feelings
have been classified as insignificant in all the cases;
only a slight feeling of swelling was noticed.
The type of incision recommended for the best possible intraoperative view, particulary during complicated surgical removal of palatal impacted and
displaced teeth (possibly as a result of ankylosis or
root anomaly), is therefore the one best suited to the
incision of gingival margin with severance of the
vascular nerve bundle at the foramen incisivum.
Neurological symptoms such as sensory disorders
have been observed in only isolated cases. Impairment
of the patients by neurological deficiencies, which
may occur, is minor and should not be compared
with anaesthesia in the region supplying the nervus
mentalis or the nervus palatinus major.
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British Journal of Oral and Maxillofacial Surgery

The Authors
A. Filippi DDS
Y. Pohl DDS
U. Tekin DDS
Department of Oral Surgery
University of Gieen
Germany

Correspondence and requests for offprints to: Dr Andreas Filippi,

Medizinisches Zentrum fr Zahn-, Mund- und Kieferheilkunde,
Abteilung Oralchirurgie und Zahnrztliche Poliklinik,
Schlangenzahl 14, D-35392 Gieen, Germany
Paper received 30 April 1997
Accepted 16 June 1997