ABSTRACTS

34 BRITISH DENTAL JOURNAL VOLUME 193. NO. 1 JULY 13 2002

Objective
To investigate the relationships between eruption status, gender,
social class, grade of operator, anaesthetic modality and nerve
damage during third molar surgery.
Design
Two centre prospective longitudinal study.
Setting
The department of oral and maxillofacial surgery, University Hos-
pital Birmingham NHS Trust and oral surgery outpatient clinics at
Birmingham Dental Hospital.
Subjects
A total of 391 patients had surgical removal of lower third molars.
Sensory disturbance was recorded at one week post operatively.
Patients with altered sensation were followed up at one month,
three months and six months following surgery.
Results
614 lower third molars in 391 patients were removed. Forty-six
procedures (7.5%) were associated with altered sensation at one
week with three procedures (0.49%) showing persistent symptoms
at six months. Of these 46 nerve injuries, 26 (4.23%) involved the
lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All
three persistent sensations were IDN related. A logistic regression
model found that the use of a lingual retractor
2
=11.559,
p=0.003 was more significant than eruption status
2
=12.935,
p=0.007. There was no significant relationship between anaes-
thetic modality, age, social class, sex and seniority of operator.
Conclusions
There was no link between the choices of local or general anaes-
thesia and nerve damage during lower third molar removal when
difficulty of surgery was taken into account.
COMMENT
An important decision associated with any surgical procedure is
which anaesthetic modality is most appropriate. In many countries,
local anaesthesia is preferred, supplemented in appropriate cases
with sedation. In the UK, although there has been a substantial shift
from in-patient to day case surgery, substantial numbers of third
molar removals are carried out under general anaesthesia.
The reasons for surgery under local anaesthesia include more
rapid return to work, fewer demands on primary care post-
operatively and comparatively lower costs. Previous research, well
summarised in this paper, has demonstrated that predictors for
third molar removal under general anaesthesia include patients
preferences, anxiety and medical history.
1
Evidence of higher rates of surgical complications after cataract
surgery suggested that anaesthetic modality might affect the
likelihood of surgical (as well as anaesthetic) outcomes. Fitting
with this, a study in which outcome of third molar removal under
general anaesthesia and local anaesthesia was compared found
evidence of a greater risk of nerve damage if surgery was carried
out under general anaesthesia. This was a potentially important
finding since third molar removal is a high volume procedure and
nerve damage is a serious complication. The study reported here,
and a similar study published elsewhere
2
have not, however, come
to this conclusion. Research carried out by Hill et al demonstrated
little difference in the adverse event rate per tooth extracted
between procedures under local and general anaesthesia. In the
general anaesthetic group, the few unilateral procedures showed
evidence of higher risk, but the number was too small for
meaningful conclusions to be drawn.
2
Factors other than anaesthetic modality have been shown to be
significantly associated with nerve damage: for example the use of
a lingual retractor, perforation of the lingual plate, individual
surgeon, duration of operation and nerve exposure during
surgery.
3,4
These studies have all been carried out in hospital
settings where general anaesthesia remains an option.
This paper is important because it contributes to an increasing
weight of evidence that it is not appropriate to suggest to patients
that anaesthetic choice affects the risk of nerve damage. There
remains, however, other important reasons for opting for local
anaesthesia, supplemented as necessary with sedation, unless this
is precluded because of difficulty of surgery or patient choice.
Jonathan Shepherd, Professor of Oral and Maxillofacial Surgery,
University of Wales College of Medicine,
1 Edwards D J, Brickley M R, Horton J, Edwards M J, Shepherd J P. Choice of anaesthetic
and health facility for third molar surgery. Br J Oral Maxillofac Surg 1998; 36: 333-340.
2 Hill C M, Mostafa P, Thomas D W, Newcombe R G, Walker R V. Nerve morbidity
following wisdom tooth removal under local and general anaesthesia. Br J Oral
Maxillofac Surg 2001; 39: 419-422.
3 Robinson P P, Smith K G. Lingual nerve damage during third molar removal: a
comparison of two surgical methods. Br Dent J 1996; 180: 456-461.
4 Renton T, McGurk M. Evaluation of factors predictive of lingual nerve injury in third
molar surgery. Br J Oral Maxillofac Surg 2001; 39: 41 1-502.
Relationship between type of anaesthetic and nerve
damage in lower third molar surgery
Links between anaesthetic modality and nerve damage during lower third molar surgery
K. Rehman, K. Webster and M. S. Dover Br Dent J 2002; 193: 43-45
RE S E ARCH S UMMARY
There was no link between nerve damage and anaesthetic type.
Third molar uneruption was a predictor for nerve injury.
Retraction of lingual nerve was strongly associated with nerve
damage.
There was no association between age of the patient and nerve
damage.
Seniority of the operator had no effect on the morbidity of the both
lingual and IDN.
I N BRI E F