Invited Review Paper

Oral Surgery
Risk factors of neurosensory
decits in lower third molar
surgery: an literature review of
prospective studies
Y. Y. Leung, L. K. Cheung: Risk factors of neurosensory decits in lower third molar
surgery: an literature review of prospective studies. Int. J. Oral Maxillofac. Surg.
2011; 40: 110. # 2010 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.
Y. Y. Leung, L. K. Cheung
Discipline of Oral and Maxillofacial Surgery,
Faculty of Dentistry, the University of
Hong Kong, Hong Kong
Abstract. This literature review assessed the risk factors linked to inferior dental
nerve (IDN) and lingual nerve (LN) decits following lower wisdom tooth
surgery. A computer search of several databases with specied key words was
performed. 32 articles were selected; the risk factors for IDN decit were reported
in 4 articles, LN in 9 and both IDN and LN in 19. Data were analysed statistically
to evaluate the potential risk factors. Literature review showed specic
radiographic signs and intra-operative IDN exposure increased the risk of IDN
decit. Raising the lingual ap signicantly increased the risk of LN decit.
Unerupted tooth and lingual split technique increased IDN and LN decit risks
signicantly. Age was linked to IDN and LN decits, and deep impaction was
related to IDN decit, but no statistical tests were performed on these two risk
factors owing to the heterogeneity of data from the studies. This literature review
found increased age, unerupted tooth, deep impaction, specic radiographic signs,
intra-operative IDN exposure and lingual split technique were risk factors for
IDN decit; increased age, unerupted tooth, distal impaction, raising of lingual
ap and lingual split technique were risks factors for LN decit in lower wisdom
tooth surgery.
Key words: neurosensory decit; third molar
surgery; literature review.
Accepted for publication 13 September 2010
Available online 28 October 2010
Neurosensory decit is a complication
after lower wisdom tooth surgery and its
occurrence is not uncommon. The risk of
developing inferior dental nerve (IDN)
decit ranges from 0.26 to 8.4% in the
literature
8,10,11,13,18,19,22,27,64,65,77,78,83,94,95,
97,100,105,110,112
, and the risk of lingual
nerve (LN) decit ranges from 0.1 to
22%
8,18,19,52,56,61,64,67,83,94,95,97,100,103,120
.
Patients with IDN decit suffer from para-
esthesia, anaesthesia or dysaesthesia of the
lip, chin or buccal gingivae of the affected
side, whilst those with LN decit have
altered sensation of the tongue with or
without taste disturbance. A small portion
of the affected population do not recover
fully in the long term
17,54
. Researchers have
tried to identify the risk factors for neuro-
sensory decits in lower wisdom tooth sur-
gery to minimize the risk of these
morbidities. Many studies have been pub-
lished but the results vary.
Evidence-based medicine provides bet-
ter information for patient management.
Integrating the best available evidence and
the individual patients circumstances
improves the quality of service delivered
to the patient
114
. In oral and maxillofacial
surgery, evidence-based research is rela-
tively scarce and there are few systematic
Int. J. Oral Maxillofac. Surg. 2011; 40: 110
doi:10.1016/j.ijom.2010.09.005, available online at http://www.sciencedirect.com
0901-5027/0101 +10 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
reviews and literature review
60
. This study
aimed to identify all available relevant
prospective studies in the literature relat-
ing to the risk factors for IDN and LN
decits in lower wisdom tooth surgery, to
provide an literature review.
Materials and methods
Computer databases, including PubMed,
Ovid and the Cochrane Library, were
searched from the earliest available date
to 8 June 2007. No language restrictions
were applied. The electronic search was
performed using the keywords: 1, third
molar; 2, wisdom tooth; 3, inferior alveo-
lar nerve; 4, inferior dental nerve; 5,
lingual nerve; 6, trigeminal nerve; 7,
nerve damage; 8, sensory disturbance; 9,
sensory decit; 10, sensory impairment;
11, nerve injury; 12, (1 OR 2) AND (3
OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10
OR 11).
The abstracts were reviewed by two
independent judges (LYY and LWK).
Articles relevant to the study of wisdom
tooth surgery and neurosensory decit
were selected. If there was inadequate
information in the abstracts or the
abstracts were missing, the articles were
included in this round. Full articles were
obtained for all those included in the rst
round. Any disagreements between the
two judges were solved by consensus. If
an agreement could not be reached, a third
party (CLK) was consulted.
Further search were performed from the
reference list of all the articles included in
the rst round. Articles relevant to the
study of wisdom tooth surgery and neu-
rosensory decit were selected. Together
with the articles obtained in the rst round,
all articles were evaluated. Two indepen-
dent judges (LYY and TI) carried out
independent evaluation of the articles
entered this round, according to the fol-
lowing criteria: articles must be limited to
wisdom tooth surgery; articles must spe-
cically list the neurosensory decit that
the subjects experienced; articles must be
randomized clinical trials, controlled clin-
ical trials or prospective clinical studies.
Articles had to fulll all these criteria to
enter the third round. Any disagreements
between the two judges were solved by
consensus. A third party (CLK) was con-
sultedif anagreement couldnot be reached.
Articles meeting the listed criteria were
entered into the third round for evaluation.
Articles entering the third round were
evaluated by two independent judges
(LYY and TI) based on the following
criteria. First, the articles must contain
one or more of the following pieces of
information about all the patients who
underwent surgery: basic demographic
data (mean age or gender of patients);
tooth status (status of eruption, depth of
impaction or pattern of impaction of the
lower third molar); radiographic signs of
the lower wisdom tooth root in relation to
the IDN; intra-operative data (exposure of
IDN, raising of lingual ap, surgical
approach or instrument used); and the
surgeons experience. Second, the articles
must contain one or more pieces of infor-
mation about whether the subjects covered
by the rst criterion suffered from post-
operative neurosensory decit.
Articles had to fulll both criteria to be
included in the nal review and literature
review. Any disagreements between the
two judges were solved by consensus. A
third party (CLK) was consulted if an
agreement could not be reached.
The data were analysed statistically
using GraphPad InStat 3.0, using t-tests
to compare continuous data and x
2
tests or
Fishers exact tests to compare categorical
data. A 5% level of signicance was
applied.
Results
367 potential articles were found in
Pubmed, an extra 20 articles in Ovid
and an additional 11 articles in the
Cochrane Library. The abstracts of these
articles were screened and 112 articles
were considered to be relevant to wisdom
tooth surgery and neurosensory decit,
and were channeled into the second round
search and evaluation.
12 articles were selected from the refer-
ence search of the 112 articles entering the
rst round. One submitted article from the
authors centre was also included
24
. 125
articles were evaluated by the two inde-
pendent judges based on the three criteria
listed in the second round evaluation. One
article was not retrievable. 2 articles were
found to be a double submission using the
same data set. 77 articles did not fulll one
or more of the three criteria. 80 articles
were excluded. 45 articles entered the
third round evaluation (Fig. 1).
Of the 45 articles entering the third
round of evaluation, 13 articles not ful-
lling the criteria listed in this round were
excluded. 32 articles were considered sui-
table for nal review. 4 of these reported
IDN decits, 9 reported LN decits and 19
reported both IDNand LNdecits. 7 of the
32 selected studies were randomized clin-
ical trials and 25 were prospective clinical
studies (Table 1).
Age and gender of the patients, eruption
status, depth and pattern of impaction of
the lower wisdom teeth, specic radio-
graphic signs indicating proximity of tooth
root to the IDN, intra-operative exposure
of IDN, surgical technique and instrument
used, and operators experience were
selected for analysing the risk in IDN
decit. Age and gender of the patients,
eruption status, depth and pattern of
impaction of the lower wisdom teeth,
whether the lingual ap was raised, surgi-
cal technique and instrument used, and
operators experience were selected for
analysing the risk in LN decit. The
literature review was limited to lower
wisdom tooth surgery using the buccal
approach (except for the analysis of sur-
gical techniques) to maximize the homo-
geneity of the data.
Risk factors for IDN decit
The risk factors for IDN decit in lower
third molar surgery are shown in Table 2.
Basic demographics
The mean age of the 8357 patients in 6
studies
8,13,24,46,117,126
was 27.1 years, of
these the mean age of the 211 patients
presenting with IDN decit was 32.3
years. The mean age of the patients with
postoperative IDN decit was greater than
that of the patients without IDNdecit. No
statistical tests were performed as several
studies did not report the standard devia-
tion of the age in their data.
Regarding gender, 3091 females and
4091 males from7 studies
10,13,16,17,24,65,117
were included. The incidence of IDNdecit
in females and males was 1.8% and 1.3%,
respectively. No statistical difference was
noted between the genders contributing to
the risk of IDN decit (p = 0.1648).
Tooth status
2 studies
22,24
with 5621 subjects described
the relationship between eruption status
and IDN decit. Incidences of IDN decit
in fully erupted, partially erupted and
unerupted lower wisdom teeth were
0.3%, 0.7% and 3.0%, respectively. Exci-
sion of unerupted lower wisdom teeth had
a higher risk of IDN decit (p < 0.0001).
There were 3 studies describing the
relation of depth of impaction and IDN
decit risk
17,24,46
. Different methods of
depth measurement were used in these
studies. One study categorized the level
of the occlusal surface in relation to the
adjacent molar
46
. Another study
17
used
the Pell and Gregory classication and
one
24
used Winters classication as a
measurement method. No literature
2 Leung and Cheung
review was attempted in this category
because of the heterogeneity of the data
available. All 3 studies showed the risk of
IDN decit was increased with the depth
of the impacted lower wisdom teeth.
5 studies
8,16,17,22,24
with 7256 subjects
described the relationship between pattern
of impaction and IDN decit. The inci-
dence of IDN decit was highest in hor-
izontally impacted lower wisdom teeth
(1.7%), followed by distal impaction
(1.4%), mesial impaction (1.3%) and ver-
tical impaction (1.1%). No statistical dif-
ferences were found between the groups
(p = 0.4632).
Radiographic signs
964 subjects from 2 studies
9,93
were
included. The incidence of IDN decit
was highest in lower wisdom teeth show-
ing radiographic sign of diversion of
ID canal by its root (30%), followed
by darkening of root (11.6%) and
deected root by the ID canal (4.6%).
These 3 signs were found to increase the
risk of IDN decit signicantly
(p < 0.0001). Other signs were not
found to be associated with the risk of
IDN decit.
Risk factors of neurosensory decits in lower third molar surgery 3

Electronic Search
Pubmed : 367 hits
Ovid : Extra 20 hits
Cochrane Library: extra 11 hits
Total 398 articles
112 relevant articles
First Round Search
Abstracts screened
286 articles irrelevant
and were excluded
Second Round Search and Evaluation
Reference
Search:
12 articles
112 articles 1 submitted
article from
our centre
Total : 125 articles
Evaluation: 3 criteria
- 1 paper not retrievable
(39)
- 2 papers double
submission (47,119)
- 77 not fulfilling the
criteria (1, 3, 4, 6, 7, 12,
15, 18, 20, 21, 23, 25-28,
30-34, 36, 37, 40, 41, 48-
51, 53, 55-59, 61, 63, 66-
70, 72-77, 80, 81, 83, 84,
86, 89, 90, 96, 98, 99,
101-111 113, 115, 116,
118, 122, 123, 125, 129,
130)
Total 80 articles
excluded
45 articles
Third Round Evaluation
45 articles
Evaluation: 2 criteria
32 articles (Table 1)
Final Review
13 articles not
fulfilling the
criteria and were
excluded (14, 35,
42, 52, 61, 82, 85,
88, 112, 120, 124,
126, 128)
Fig. 1.
Intra-operative data
5 studies
9,10,46,62,117
with 2028 subjects
reported the incidence of IDN decit when
the IDN was exposed during surgery.
16.2%of the surgery with the IDNexposed
developedpostoperative IDNdecit, whilst
only 1.1% of the surgeries without IDN
exposure developed IDN decit; this is of
high statistical signicance (p < 0.0001).
The risk ratio of IDN decit from intra-
operative IDN exposure is 14.9 times more
likely than if the IDN is not exposed.
20 studies
2,8,911,16,17,19,24,46,54,62,65,71,
79,87,94,95,117,121
reported the surgical tech-
nique and postoperative IDN decit. Sur-
gery on 12,100 lower third molars used the
buccal approach, 1869 surgeries used the
lingual split technique and 108 lower wis-
dom teeth underwent coronectomy. The
incidences of IDN decit following the
buccal approach, lingual split technique
and coronectomy were 2.5%, 5.7% and
0%, respectively. The lingual split techni-
que had a signicantly higher risk of IDN
decit compared with the buccal approach
and coronectomy (p < 0.0001). The risk
ratio of IDN decit is therefore 2.3 times
more likely using the lingual split techni-
que than the buccal approach.
18 studies
2,9,10,11,13,16,17,19,24,46,54,65,71,79,
87,94,95,117
reported the type of instruments
used in the lower wisdomtooth surgery. All
surgery performed with chisel and mallet
usedthe lingual split technique, whilst drills
were used in all buccal approaches or cor-
onectomy. No attempt was made to mea-
sure the effect of the instruments on the risk
of IDN decit because it would be more
appropriate to relate risk to the surgical
technique.
Surgeons experience
There were 13,055 subjects in the 11
studies
8,9,13,16,17,19,24,79,87,95,117
that
reported the experience of the operators.
The incidence of IDN decit was highest
in the specialist/consultant group (2.9%),
followed by the trainee/resident group and
undergraduates with 1.3% and 0.2%,
respectively (p < 0.0001).
Risk factors for LN decit
The risk factors for LN decit in lower
third molar surgery are shown in Table 3.
Basic demographics
7559 patients in 5 studies
8,13,19,24,43
were
included with a mean age of 27.1 years.
The mean age of the 101 patients present-
ing with LN decit was 32.2 years. The
mean age of the patients with postopera-
tive LN decit was greater than that in
patients without LN decit. No statistical
tests were performed as several studies did
not report the standard deviation of the age
in their data.
Regarding gender, 3088 females and
4082 males from 7 studies
10,13,16,17,24,29,65
were included. The incidence of LNdecit
4 Leung and Cheung
Table 1. Articles for the nal review and the risk factors presented in these articles (n=32).
Ref. Authors Year
Study
design
Decit
reported
Risk
factors 1 2 3 4 5 6 7 8 9 10 11
19
BRUCE et al. 1980 Pros Both + + + +
95
ROOD 1983 Pros Both + + +
64
MASON 1988 Pros LN +
65
MIDDLEHURST et al. 1988 RCT Both + + + +
71
OBIECHINA 1990 Pros Both + + +
93
ROOD and SHEHAB 1990 Pros IDN +
22
CARMICHAEL and
MCGOWAN
1992 Pros Both + + +
94
ROOD 1992 Pros Both + +
2
ABSI and SHEPHERD 1993 RCT Both + +
16
BLONDEAU 1994 Pros Both + + + + + +
11
BERGE and BE 1994 Pros Both + +
45
GREENWOOD et al. 1994 Pros LN + +
92
ROBINSON and SMITH 1996 RCT LN + +
13
BLACK 1997 Pros Both + + + +
5
APPIAH-ANANE and
APPIAH ANANE
1997 Pros LN + +
91
ROBINSON et al. 1999 Pros LN + + +
38
GARGALLO-ALBIOL et al. 2000 RCT LN + + +
121
VALMASEDA-CASTELLON et al. 2001 Pros IDN +
8
BATAINEH 2001 Pros Both + + + + + +
46
GULICHER and GERLACH 2001 Pros Both + + + + + + +
29
CHOSSEGROS et al. 2002 RCT LN + + + + + + +
62
MAEGAWA et al. 2003 Pros IDN + + +
79
POGREL et al. 2004 Pros Both + + + +
78
POGREL and GOLDMAN 2004 Pros LN + + + +
117
TAY and GO 2004 Pros IDN + + + + +
10
BENEDIKTSDO

TTIR et al. 2004 Pros Both + + + +

9
BELL et al. 2004 Pros Both + + + + +
43
GOMES et al. 2005 RCT LN + + + +
87
RENTON et al. 2005 RCT Both + + +
54
JERJES et al. 2006 Pros Both + + +
17
BLONDEAU and DANIEL 2007 Pros Both + + + + + +
24
CHEUNG et al. 2008 Pros Both + + + + + + + + +
RCT: randomized controlled trial; Pros: prospective clinical studies; risk factors assessed: 1, age; 2, gender; 3, eruption status; 4, depth of
impaction; 5, pattern of impaction; 6, radiographic signs; 7, IDNexposure; 8, lingual ap; 9, surgical technique; 10, instrument used; 11, operators
experience.
in females and males was 0.7% and 0.3%,
respectively. No statistical difference was
found (p = 0.064).
Tooth status
3 studies
22,24,29
with 5875 subjects
described the relationship between erup-
tion status and LN decit. Incidences of
LN decit in fully erupted, partially
erupted and unerupted lower wisdom teeth
were 0.3%, 2.0% and 5.8%, respectively.
Surgery on unerupted lower wisdom teeth
was at higher risk of LN decit compared
with erupted or partially erupted teeth
(p < 0.0001).
The 3 studies
17,24,46
presenting the rela-
tion of impaction depth and risk of LN
decit used different methods of depth
measurement. No literature review was
attempted in this category owing to the
heterogeneity of the data available. All 3
studies agreed that the risk of LN decit
did not increase with the depth of the
impacted lower wisdom teeth.
5 studies
8,16,17,22,24
with 7256 subjects
described the relationship between the
pattern of impaction of lower wisdom
teeth and IDN decit. The incidence of
LNdecit was highest in distally impacted
lower wisdom teeth (4.0%), followed by
horizontal impaction (2.8%), mesial
impaction (2.4%) and vertical impaction
(1.9%). Distally impacted lower wisdom
teeth have a signicantly higher risk of LN
decit compared with other patterns of
impaction (p < 0.01).
Intra-operative data
16 papers
5,8,16,24,29,38,43,45,46,54,65,71,78,79,
91,92
with 10,893 subjects reported whether
the surgery included raising the lingual ap
or not. 3.1% of the surgeries with lingual
ap raised showed LN decit postopera-
tively, whilst only 1.5% of LN decit
occurred in surgery in which the lingual
ap was not raised. This difference was
highly signicant (p < 0.0001). The risk
ratio of LN decit was 1.94 times more
likely to occur if the lingual ap was raised
than if it was not.
26 studies
2,5,811,16,17,19,24,29,38,43,45,46,54,
64,65,71,78,79,81,91,92,94,95
reported the surgi-
cal technique and postoperative LN decit.
Surgeries on 14,555 subjects used the buc-
cal approach, the lingual split technique was
used in 2162 subjects and 144 subjects
underwent coronectomy. The incidences
of LN decit using the buccal approach,
lingual split technique and coronectomy
were 2.3%, 9.3% and 0.7%, respectively.
The lingual split technique had a higher risk
of LN decit compared with the other two
surgical techniques (p < 0.001). The risk
ratio of lingual nerve decit using the lin-
gual split technique is considered 4.1 times
more likely than when using the buccal
approach.
23 studies
2,811,13,16,17,19,22,24,29,38,46,54,
65,71,78,79,87,94,95
specied the instruments
used in the lower wisdom tooth surgery.
All surgery performed with chisel and
mallet used the lingual split technique,
whilst drills were used in all buccal
approaches or coronectomy. No attempt
was made to measure the effect of instru-
ments on the risk of LN decit as it would
be more appropriate to relate risk to the
surgical technique.
Surgeons experience
There were 13,391 subjects in the 15
studies
8,9,13,16,17,19,24,29,43,46,78,79,87,91,95
that reported the experience of operators.
The incidence of LN decit in the specia-
Risk factors of neurosensory decits in lower third molar surgery 5
Table 2. Risk factors for IDN decit after lower wisdom tooth surgery.
Risk factor (included articles)
Total no. of
subjects included
No. of subjects
with decit Decit % p-Value
Age (
8,13,24,46,117,126
) Mean age of
all subjects = 27.12 years
Mean age of decit
subjects = 32.25 years
No test
performed
Gender (
10,13,16,17,24,65,117
) 0.1648
Female 3091 55 1.8
Male 4091 55 1.3
Eruption status (
22,24
) <0.0001
*
Erupted 310 1 0.3
Partially erupted 4011 27 0.7
Unerupted 1300 39 3.0
*
Pattern of impaction (
8,16,17,22,24
) 0.4632
Mesial 3321 43 1.3
Distal 841 12 1.4
Vertical 1543 17 1.1
Horizontal 1551 27 1.7
Radiographic signs (
9,93
) <0.0001
No radiographic relationship 658 0 0
Deected root 69 8 11.6
Narrowing root 3 0 0
Dark bid root 6 0 0
Interruption of white line 145 0 0
Diversion of ID canal 20 6 30
Narrowing of ID canal 19 0 0
IDN exposure (
9,10,46,62,117
) <0.0001
Yes 382 62 16.2
No 1646 18 1.1
Technique (
2,8,9,10,11,16,17,19,24,46,54,62,65,71,79,87,94,95,117,121
) p < 0.0001
*
Buccal approach 12,100 296 2.5
Lingual split technique 1869 107 5.7
*
Coronectomy 108 0 0
Experience (
8,9,13,16,17,19,24,79,87,95,117
) <0.0001
Specialists/consultants 8595 245 2.9
Trainees/residents 2482 33 1.3
Undergraduates 1978 4 0.2
list/consultant group, trainee/resident
group and undergraduate group were
0.9%, 1.0% and 1.2%, respectively. No
statistical differences between the groups
were noted (p = 0.404).
Discussion
The risk factors for IDN decit in lower
wisdom tooth surgery were found to be
increasing age, unerupted tooth, deep
impaction, specic radiographic signs,
intra-operative IDN exposure and using
the lingual split technique. The risk factors
for LN decit in lower wisdom tooth
surgery were increasing age, unerupted
tooth, distal impaction, raising of lingual
ap and using the lingual split technique.
The mean age of the patients with post-
operative LN or IDN decit was greater
than for those without neurosensory def-
icit. Many authors proposed that technical
difculty increases with age owing to
reduced bone elasticity and a higher inci-
dence of hypercementosis of the wisdom
teeth, and these might account for the
higher risk of neurosensory decit
13,19
.
Gender does not contribute to the risk of
neurosensory decit, which agrees with all
the reported studies
10,13,16,17,24,117
.
The status of the wisdom teeth also
contributes to the risk of neurosensory
decit. Unerupted lower wisdom teeth
can signicantly increase the risks of
IDN and LN decits. This correlates well
with the increasing depth of impaction. Its
relationship with LN decit could be
explained by the probable need to use a
lingual retractor during surgery, which
itself increased the risk of LN decit
22
.
The increased risk of IDN decit post-
operatively was associated with deeper
impaction, probably because of the closer
proximity of the tooth roots to the IDN.
Reduced surgical accessibility and visibi-
lity could contribute to this morbidity.
Depth of impaction was not found to be
a risk factor for LN decit in this literature
review. The pattern of impaction was not
found to contribute to the risk of IDN
decit. Rather than the angulation of tooth
impaction, the proximity to the IDN and
the relationship of the root and the nerve
presenting specic radiographic signs
seemed to be more directly related. Dis-
tally impacted lower wisdom teeth were
more prone to LN decit. It has been
suggested that the larger amount of distal
bone removed, including the lingual cor-
tex, to facilitate the path of tooth with-
drawal could inadvertently damage the
LN
8,24
.
The proximity of the tooth roots to the
IDN is best assessed by computer tomo-
graphy (CT), although CT might be too
expensive or inconvenient for the assess-
ment of every third molar case. Plain
radiography, such as orthopantography,
is the most common investigation before
wisdom tooth surgery; it provides an over-
view of the status of all wisdom teeth in
two dimensions. Several specic radio-
graphic signs that indicate wisdom tooth
roots are close to the IDN were proposed
by several authors
9,15,44,93
. In this study,
diversion of IDN, darkening of root and
defected root were positively associated
with an increased risk of IDN decit,
whilst other signs were not found to be
associated. Only two studies were
included in the nal review
9,93
. The aggre-
gated sample size was small. Prospective
studies with larger sample sizes to deter-
mine the risk of IDN decit associated
with specic radiographic signs are
required.
IDN exposure was a known risk factor
in 5 of the studies
9,10,62,90,117
. The relative
risk of IDN exposure in developing IDN
decit is approximately 15 in the present
literature review. IDN exposure indicates
there is an intimate relationship between
the roots and the IDN. The patient is
subjected to a much higher risk of IDN
damage because a compression or crush
injury to the nerve could occur during root
elevation
117
.
Whether to raise a lingual ap in third
molar surgery has been a topic of hot
debate over the past decade. Despite a
well conducted systematic review by PICH-
LER and BEIRNE
77
showing an increased
6 Leung and Cheung
Table 3. Risk factors for LN decit after lower wisdom tooth surgery.
Risk factor (included articles)
Total no. of
subjects included
No. of subjects
with decit Decit % p-Value
Age (
8,13,19,24,43
) Mean age of
all subjects
= 27.09 years
Mean age of
decit subjects
= 32.24 years
No test
performed
Gender (
10,13,16,17,24,29,65
) p = 0.0644
Female 3088 23 0.7
Male 4082 16 0.4
Eruption status (22,24,29) p < 0.0001
*
Erupted 310 2 0.7
Partially erupted 4011 80 2.0
Unerupted 1554 90 5.8
*
Pattern of impaction (
8,16,17,22,24
) p < 0.01
*
Mesial 3321 78 2.4
Distal 841 34 4.0
*
Vertical 1543 29 1.9
Horizontal 1551 43 2.8
Raising of lingual ap (
5,8,16,24,29,38,43,45,46,54,65,71,78,79,91,92
) p < 0.0001
Yes 4190 129 3.1
No 6703 102 1.5
Technique (
2,5,8,9,10,11,16,17,19,24,29,38,43,45,46,54,64,65,71,78,79,81,91,92,94,95
) p < 0.001
*
Buccal approach 14,555 333 2.3
Lingual split technique 2162 201 9.3
*
Coronectomy 144 1 0.7
Experience (
8,9,13,16,17,19,24,29,43,46,78,79,87,91,95
) p = 0.404
Specialists/consultants 8135 75 0.9
Trainees/residents 3078 32 1.0
Undergraduates 2178 27 1.2
risk of LN decit with lingual ap retrac-
tion, POGREL foundthat it had noassociation
with the risk of LN decit and the decit
following lingual retraction was likely to be
temporary
78
. The result of this literature
review supports the ndings of PICHLER
and BEIRNE, with a risk ratio for LN decit
with lingual ap retraction being 1.94 times
more likely than without lingual ap retrac-
tion. This showed an increased risk of LN
decit for the short term; no attempt was
made to compare long term recovery in
these groups owing to the heterogeneity
of the follow-up periods.
Different surgical techniques for
removing wisdom teeth have been pro-
posed. The lingual split technique
described by WARD in 1956
127
is still used
by some surgeons, although it has been
abandoned by many centres due to the
higher risk of LN injury. Worldwide, most
lower wisdom tooth surgery uses the buc-
cal approach. Recently, coronectomy,
which intentionally removes the crown
of a wisdom tooth without taking out its
roots, has become more popular owing to
the smaller risk of IDN injury shown in
several studies
74,79,87
. In this study, the
lingual split technique was conrmed to
be signicantly associated with the risks of
IDN and LN decit compared with the
buccal approach and coronectomy. The
authors support the view that the lingual
split technique should not be used because
of its signicant neurosensory morbidity.
There was a higher rate of IDNdecit in
surgery performed by specialists/consul-
tants than surgical trainees/residents and
the least amongst undergraduates. It was
not possible to compare the difculty and
status of the wisdom teeth in these groups.
It was logical to assume the specialists/
consultants were dealing with the more
difcult or deeper third molars compared
with the operators with less surgical
experience, and these factors made them
more prone to cause postoperative IDN
decit. This was true in at least one of the
included studies
24
. There was no associa-
tion between the surgical experience of the
operators and LN decit in this study.
Regarding potential bias in the review
process, language bias was minimal by not
posing any language restriction. Quality
assurance was fostered with two indepen-
dent judges in all rounds of selection and
the reference search. The heterogeneity of
the data in the studies cannot be avoided
but the authors attempted to minimize it by
performing statistical tests only on homo-
geneous data. There may be some degree
of publication bias because some studies
only reported on data with positive nd-
ings.
For future research, the authors recom-
mend a standardized methodology and fol-
low-up for measuring neurosensory decit
in future third molar surgery studies.
Assessment of neurosensory recovery
was not attempted largely due to the
expected variation in quantifying the neu-
rosensorydisturbance as well as differences
infollow-upperiods inthe different studies.
Coronectomy, as a technique to minimize
IDN decit, has been proposed for two
decades and recent studies show promising
results. Only one randomized controlled
trial has been published
87
. Well designed
randomized controlled trials with a large
sample size are indicated to investigate the
value and safety of this technique.
The timing of neurosensory recovery in
relation to the various demographic and
operative parameters was not analysed in
this study because of the heterogeneity of
the studies and possible hidden confound-
ing factors within the analysis. Future
systematic reviews and literature review
on the factors affecting the timing of
neurosensory recovery should be con-
ducted on randomized controlled trials
to build up a more homogenous database.
In conclusion, this literature review of
prospective studies found that increased
age, unerupted tooth, deep impaction, spe-
cic radiographic signs, intra-operative
IDN exposure and the lingual split techni-
que were risk factors for IDN decit;
increased age, unerupted tooth, distal
impaction, raising of lingual ap and the
lingual split technique are risks factors for
LN decit in lower wisdom tooth surgery.
Funding
None.
Conict of interest
None.
Ethical approval
Not required.
Acknowledgements. The authors would
like to thank Dr Wing Kit Li and Dr Ivan
Tsui for participating in this research as
independent judges in the article selection
process, and Dr Mei Chong for her con-
tributions to this research.
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Address:
Lim Kwong Cheung
Oral & Maxillofacial Surgery
Prince Philip Dental Hospital
34 Hospital Road
Hong Kong
Tel: +852 28590267
Fax: +852 28575570
E-mail: lkcheung@hkucc.hku.hk
lkcheung@hku.hk
10 Leung and Cheung