Lingual Split Technique Research Articles

Evaluation of postoperative complications after removal of mandibular third molar by conventional bur technique and lingual split technique

ABSTRACT Aim: The objective of this study was to evaluate the effect and safety including postoperative outcomes in the extraction of impacted mandibular third molar by conventional bur technique and lingual split technique. Methods, Selection Criteria, and Search Strategy: A total of 40 healthy individuals, both male and female, aged from 18 to 40 years, underwent surgical removal of impacted mandibular third molars under local anesthesia in a single session. An intensive electronic search was conducted on Google, PubMed, Scopus, Embase, Directory of Open Access Journals, Ovid Medline, and Cochrane Central online databases from their respective inception dates to November 2020. Initially, the search criteria included the terms: ((mandibular OR lower) AND (third molar OR wisdom) AND lingual split). The following outcomes were investigated: pain, swelling, trismus, and dry socket on the first day before surgery, the second (post 24 h), and on the seventh day. Results and Observations: The present retrospective comparative study evaluates the postoperative complications after the removal of the third molar. A total of 40 subjects of either sex were randomized to be treated either with the conventional bur technique (Group A) or the lingual split technique (Group B). The ages of Groups A and B ranged from 19 to 40 years and from 19 to 42 years, respectively, with a mean ± SD of 26.20 ± 6.01 and 27.15 ± 6.21 years, respectively. The mean age of Group B was slightly higher than Group A. Comparing the mean age of the two groups, t-test revealed similar (P > 0.05) age between the two groups (26.20 ± 6.01 vs. 27.15 ± 6.21, t = 0.49; P = 0.626). The subjects in both groups were age-matched, suggesting that age may have had minimal influence on the outcome measures (swelling, trismus, and pain). Conclusion: In the realm of mandibular third molar (M3) extraction, it is acknowledged that this surgical procedure can present challenges, and there exists a diversity of professional approaches between dentists and oral surgeons. Prior to determining a treatment course for each M3, it is imperative to possess a comprehensive understanding of the pertinent anatomical structures, including the inferior dental and lingual nerves. Additionally, a thorough clinical assessment and the utilization of radiographic imaging are essential for carefully evaluating each case and balancing the advantages and disadvantages of various treatment plans. Timely removal of the third molar (tooth M3) can significantly reduce the adverse complications associated with delayed extraction.

Incidence of lingual nerve damage following surgical extraction of mandibular third molars with lingual flap retraction: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to examine more recent data to determine the extent of lingual nerve injury (LNI) following the surgical extraction of mandibular third molars (M3M). A systematic search of three databases [PubMed, Web of Science and OVID] was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria encompassed studies on patients who underwent surgical M3M extraction using the buccal approach without lingual flap retraction (BA-), buccal approach with lingual flap retraction (BA+), and lingual split technique (LS). The outcome measures expressed in LNI count were converted to risk ratios (RR). Twenty-seven studies were included in the systematic review, nine were eligible for meta-analysis. Combined RR for LNI (BA+ versus BA-) was 4.80 [95% Confidence Interval:3.28-7.02; P<0.00001]. The prevalence of permanent LNI following BA-, BA+ and LS (mean%±SD%) was 0.18±0.38, 0.07±0.21, and 0.28±0.48 respectively. This study concluded that there was an increased risk of temporary LNI following M3M surgical extractions using BA+ and LS. There was insufficient evidence to determine whether there is a significant advantage of BA+ or LS in reducing permanent LNI risk. Operators should use lingual retraction with caution due to the increased temporary LNI risk.

Lingual split bone technique – Revisited as a standard operating procedure for surgical removal of third molar during COVID pandemic

Objectives: The objective of the study is to revisit the forgotten art of Lingual split bone technique during the COVID pandemic as a Standard Operating Procedure (SOP) for the surgical removal of impacted mandibular third molars. It was originally introduced in early 90’s by Sir William Kelsey Fry and also we have compared its advantages over the bone guttering technique. Materials and Methods: Twenty seven cases were operated during COVID pandemic in our institution using Davi’s modified lingual split technique under strict COVID protocol. Results: All impacted mandibular third molars were successfully removed. With regards to post-operative complication; 3 patients had nerve injury (11%), 2 patients had lingual paraesthesia (7.6%), 1 patient had alveolar osteitis (3.8%), 2 patients had postoperative infection (7.6%), 3 patients had trismus (19%). The overall success rate was 100%. Also the results of a comparison between bone guttering and chisel-mallet technique were stated. Conclusion: The use of lingual split bone technique deserves consideration during this COVID time as an alternate for bone guttering in surgical removal of third molar as it ensures minimal cross infectivity rate among both dentists and patients. Thus, patient care can be delivered with confidence even during pandemic.

English

The average time consumed for disimpaction of mandibular third molar using rotatory instruments was approximately 17 mins and 23 mins while using a piezotome. The authors introduce a new technique of disimpaction of mandibular third molar with the least amount of bone removal ever achieved during mandibular third molar removal. This technique can be readily included in routine clinical practice and can be performed by using routine rotary instruments. This technique was successfully accomplished in 10 individuals with the least amount of discomfort and post-operative complications reported from day 1 to day 14. The procedure was evaluated based on time of the procedure, pain score, bleeding, nerve injury, trismus, swelling &amp; dry socket. Third molar removal has been the most frequently performed oral surgical procedure in the modern world of dentistry.1 Although, mandibular third molar is the most commonly performed procedure, it demands skill, technique and experience. Several techniques have been implied for disimpaction of mandibular third molar, but every method involves either considerable amount of bone removal or splitting the bone. Bone manipulation is done by using a rotary instruments or chisel and mallet. The most popular techniques are buccal bone guttering, distal bone removal, lingual bone split technique and lingual bone guttering.2 According to the traditional classifications of impacted mandibular third molar (Pell &amp; Gregory and Winter’s classification), the minimum amount of bucco-distal bone removed during disimpaction of mesioangularly positioned class I A impacted mandibular third molar using rotary instruments and conventional techniques can be calculated as 157.5 mm2 (volume of a rectangle = L X W X H; where L = 15 mm, W = 1.5 mm [width of the bur] and H = 7 mm). The mandibular third molar requiring osteotomy and tooth section have the highest risk of complications3. Surgical time had significantly increased in cases which required osteotomy and tooth section. Post-operative swelling and pain has been recorded as significant complications after using rotary instruments via buccal approach followed by use of chisel &amp; mallet and least in lingual split approach. On the contrary, post-operative nerve injury and trismus were significantly high in lingual split technique. Dry socket was more in patients of bur technique.2

Lingual Short Split: A Bilateral Sagittal Split Osteotomy Technique Modification.

The technique of sagittal split osteotomy of the mandibular ramus is an established technique that has been evolving over the years, with significant improvements regarding stability, better bone contact between the segments, and possibilities of osteosynthesis. However, paresthesia is common in the postoperatory, sometimes permanent, and undesirable fractures in the subcondylar region can occur leading to longer operative time and extraoral scars. The short lingual split technique is an easy technique that simplifies the horizontal osteotomy of the ramus and decreases the risk of undesirable fractures with a neurosensitive recovery of patients in a much shorter time because of minor trauma and nerve manipulation during the execution.

Current practice in mandibular third molar surgery. A national survey of British Association of Oral Surgeons membership

AbstractObjectiveThe aim of this survey was to evaluate current practice in mandibular third molar (M3M) surgery within the British Association of Oral Surgeons (BAOS) membership against current evidence and relevant guidelines.MethodAn online questionnaire survey was active from March to June 2015.ResultsA total of 250 BAOS members (48%) responded to the survey. About 52% were registered Oral Surgery specialists. Exactly, 36% stated that M3M surgery comprised 50–75% and 17% stated that M3M surgery comprised over 75% of their workload. About 73% would recommend coronectomy for high‐risk M3Ms; however, 53% had difficulty in accessing cone beam CT (CBCT) scanning. Most practitioners undertook a two‐stage written consent informing patients of the possibility of numbness, altered sensation or pain as a result of inferior alveolar or lingual nerve injury; however, there were significant variations in how this was communicated. Most surgeons operated mainly under local anaesthesia, using a triangular buccal flap access; 27% routinely used lingual retraction. Buccal and distal bone removal followed by sectioning of the tooth was the most common approach, although 1% routinely used the lingual split technique. Over the last 5 years, each responder reported an average of 2 temporary and 0.4 permanent inferior alveolar nerve injuries (IANI), 1 temporary and 0.1 permanent lingual nerve injuries (LNI).ConclusionThis survey has highlighted the lack of access to CBCT scanning and the differences in approach to consent and surgical technique. The reported rates of nerve injury caused by M3M surgery were low; however, this may be due to a lack of post‐operative follow up.

Piezosurgery for the Lingual Split Technique in Lingual Positioned Impacted Mandibular Third Molar Removal: A Retrospective Study.

The aim of this study was to evaluate the effect and safety of lingual split technique using piezosurgery for the extraction of lingual positioned impacted mandibular 3rd molars with the goal of proposing a more minimally invasive choice for this common surgery.Eighty-nine consecutive patients with 110 lingual positioned impacted mandibular 3rd molars requiring extraction were performed the lingual split technique using piezosurgery. One sagittal osteotomy line and 2 transverse osteotomy line were designed for lingual and occlusal bone removal. The success rate, operative time, postoperative outcome, and major complications (including nerve injury, mandible fracture, severe hematoma or edema, and severe pyogenic infection) were documented and analyzed.All impacted mandibular 3rd molars were successfully removed (110/110). The average time of operation was 14.6 minutes (ranged from 7 to 28 minutes). One hundred and seven extraction sites (97.3%) were primary healing. Pain, mouth opening, swelling, and PoSSe scores on postoperative 7-day were 0.34 ± 0.63, 3.88 ± 0.66(cm), 2.4 ± 0.2(cm), and 23.7 ± 5.9, respectively. There were 6 cases (5.5%) had lingual nerve disturbance and 3 cases (2.7%) developed inferior alveolar nerve impairment, and achieved full recovery within 2 months by neurotrophic drug treatment.Our study suggested piezosurgery for lingual split technique provided an effective way for the extraction of lingual positioned and deeply impacted mandibular 3rd molar.

Risk of lingual nerve damage: lingual split vs ostectomy with burs

I read with great interest the article entitled “Lingual split versus surgical bur technique in the extraction of impacted mandibular third molars: a systematic review,” written by Dr. Ben Steel.1 It addresses an interesting subject: whether or not extraction of lower third molars using a chisel is better than using a bur, which is the most popular method nowadays (I dare say the gold standard). This systematic review of randomized clinical trials seems insufficient to answer the question, due to the scarcity of analyzed reports, the methodological concerns (for instance, some randomized controlled trials have an insufficient power to detect differences in infrequent complications such as lingual nerve injuries) and the heterogeneity of outcomes.

Piezosurgery for the Lingual Split Technique in Mandibular Third Molar Removal

The lingual split technique is a surgical procedure for extraction of impacted mandibular third molar throughout a lingual approach. The main disadvantage of this technique is the high rate of temporary lingual nerve injury mainly because of the trauma induced by the lingual flap retraction. The purpose of this paper is to suggest the use of piezosurgery in performing the lingual cortical plate osteotomy of the third molar alveolar process. Surgical procedure was performed under general anesthesia, and it lasted approximately 60 minutes. After the buccal and lingual full-thickness flaps were incised and elevated, a piezosurgical device was used for osteotomy. A well-defined bony window was then removed, and it allowed the entire tooth was extracted in a lingual direction. The patient did not show any neurological postoperative complication. Lingual and inferior alveolar nerve functionality was normal before as well as after surgery. The use of piezoelectric surgery seems to be a good option in removing lower third molars when a lingual access is clearly indicated. The only disadvantage of this technique can be represented by an operating time lengthening possibly because of a lower power cut of the piezoelectric device, to the high mineralization of the mandibular cortical bone and to the use of inserts with a low degree of sharpening.

Techniques in the removal of impacted mandibular third molar: A comparative study

Abstract Objective: Surgical removal of impacted third molar is one of the common surgical procedures carried out in Oral and Maxillofacial Surgery set up. This study aimed at clinically assessing the three different surgical techniques (lingual split, using chisel and mallet, buccal approach techniques, using rotary instruments used in the removal of impacted mandibular third molars. Materials and Methods: The present clinical study comprised of 150 impacted mandibular wisdom teeth. Patients were divided in three groups and bone covering the third molar was removed by the Lingual split technique using chisel and mallet, Buccal approach technique using chisel and mallet, and Buccal approach technique using rotary instruments. Results: Surgical time was significantly increased in bur technique. Trismus was significantly increased in lingual split technique and bur technique from buccal approach technique using chisel and mallet. Post-operative nerve injury was significantly higher in lingual split technique. Dry socket was more in patients of bur technique. Conclusion: In this study we found that lingual split technique using chisel and mallet is found to be better among all three techniques used followed by buccal approach using chisel and mallet and the buccal approach technique using rotary instruments.

The relative risk of neurosensory deficit following removal of mandibular third molar teeth: the influence of radiography and surgical technique

The aim of this study was to identify the relative risk of damage to the inferior dental (ID) and lingual nerves in patients undergoing lower third molar removal. A single surgeon reviewed 1,000 patients. Temporary ID neurosensory deficit was highest (11%) when root apices were intimate to the ID nerve and lowest (0.9%) when close or distant from the nerve. Permanent ID neurosensory deficit was 0.4% per tooth but only when intimate to the canal. Bone removal, tooth division, and lingual split technique increase the risk of excessive hemorrhage which appears to be linked to the highest risk of temporary ID neurosensory deficit (20%). Permanent lingual nerve injury was rare (0.06%) and not related to lingual retraction. Preoperative warning for lower third molar removal can be individually tailored depending on the intimacy of the ID canal to the root apices and the anticipated surgical technique.

Lingual split versus surgical bur technique in the extraction of impacted mandibular third molars: a systematic review

The relative merits of different surgical techniques to extract impacted mandibular third molars have been debated for many years. A simple classification is those using a bur and those using a chisel. This article seeks to identify any differences in postoperative outcomes between the surgical bur and lingual split techniques. Using inclusion criteria allowing randomized controlled trials only, 5 studies are identified of which 4 are used in the analysis. The following outcomes are investigated: pain, swelling, trismus, bleeding, delayed healing/infection, and disturbance to lingual and inferior alveolar nerve function. The limited analysis allowed by the number and size of the studies leads to tentative conclusions of no difference between postoperative pain and swelling, and some evidence of less trismus for the lingual split technique. There is some weak evidence of a similar incidence of neurological sequelae between the 2 techniques, but this is not a strong conclusion owing to the small size of the included studies. There are inadequate data regarding bleeding and delayed healing/infection for analysis.

Risk factors of neurosensory deficits in lower third molar surgery: a literature review of prospective studies

This literature review assessed the risk factors linked to inferior dental nerve (IDN) and lingual nerve (LN) deficits following lower wisdom tooth surgery. A computer search of several databases with specified key words was performed. 32 articles were selected; the risk factors for IDN deficit 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 specific radiographic signs and intra-operative IDN exposure increased the risk of IDN deficit. Raising the lingual flap significantly increased the risk of LN deficit. Unerupted tooth and lingual split technique increased IDN and LN deficit risks significantly. Age was linked to IDN and LN deficits, and deep impaction was related to IDN deficit, 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, specific radiographic signs, intra-operative IDN exposure and lingual split technique were risk factors for IDN deficit; increased age, unerupted tooth, distal impaction, raising of lingual flap and lingual split technique were risks factors for LN deficit in lower wisdom tooth surgery.

Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique

The methods frequently used for surgical removal of impacted third molars are bur technique, lingual split and simplified split bone technique. The morbidity rates following the use of these different surgical techniques are not completely resolved. The use of a surgical method with minimum postoperative complication is needed. This study was conducted to compare the morbidity rates of the three different surgical techniques and their efficacy with regard to postoperative pain, swelling, labial and lingual sensation. Ninety patients with a symptomatic impacted mandibular third molar with the age range of 14-62 years were divided into three groups of 30 patients each for surgical bur technique, lingual split technique and simplified split bone technique. All patients were operated by the same surgeon under local anesthesia (2% lignocaine) in the dental chair. The severity of pain and swelling was recorded on a visual analogue scale and the presence or absence of sensory disturbance at 6, 24, 48 hours and seven days after operation. The pain was scored according to a visual analogue 4-point scale. Patients were asked to indicate which side was more swollen and to record this assessment on the swelling scale. Lingual split technique was more painful than the other two techniques. Surgical bur technique had more swelling than the other two techniques. Labial and lingual sensations were not altered in all the techniques. The simplified split bone technique had the least morbidity than the lingual split and surgical bur technique.

Frequency of trigeminal nerve injuries following third molar removal

Injuries to the lingual nerve (LN) or inferior alveolar nerve (IAN) are well-known, uncommon complications of third molar operations. However, given an adequate third molar operative volume, these are complications that will be seen by virtually all practicing oral and maxillofacial surgeons at some point during their career. Having good information regarding the frequency, temporal patterns, risk factors, and management of LN or IAN injuries can be valuable to the practitioner. The article published by Robert et al summarizes the frequency, temporal pattern (ie, temporary versus permanent), and risk factors for LN and IAN injuries following third molar removal based on self-report of practitioners who are members of the California Association of Oral and Maxillofacial Surgeons. The results can be reviewed separately in the article. While there are biases associated with using self-report to estimate frequency of LN or IAN injures, the authors’ results are comparable to other publications. As the discussant, a few comments regarding the management of LN or IAN injuries are warranted. The most important aspect of managing LN or IAN injuries is documenting and communicating the findings of the neurosensory examination in a common, understandable, defined, and accepted manner. As an academic oral and maxillofacial surgeon, my more frustrating experiences revolve around reviewing the literature on nerve injuries or discussing cases with colleagues who cannot describe better their patient’s neurosensory findings after nerve injury. At our institution, we use the neurosensory examination scoring system described by Zuniga and Essick to evaluate and monitor nerve injuries. To assess outcomes, we use functional sensory recovery. These tools provide a common language for our faculty and residents to communicate with each other. This author strongly encourages other clinicians and researchers to use these tools to document and describe the neurosensory examination findings and outcomes after LN or IAN injury. Prevention of LN or IAN injuries is an important goal in the management of third molars. The risk of LN or IAN injury is zero if the third molar is not removed. As such, explicit diagnoses and justifications for third molar removal are indicated and should be clearly documented in the patient record. There is a set of radiographic markers evident on panoramic radiograph associated with an increased risk for IAN injury. In the setting of finding 1 or more of these markers, other imaging technologies should be considered (eg, periapical films, plain tomography, or computed tomography imaging). Currently, there are no good ways to evaluate the preoperative position of the LN. However, there are a number of articles reviewing the position of the LN in the third molar region. There exist some operative techniques to limit the risk of LN injury, including incision placement, limiting lingual flap elevation, avoiding lingual-split technique or a bur injury to the lingual alveolar bone, and careful debridement of lingual soft tissue. Injuries to the LN or IAN are probably unavoidable in a busy dentoalveolar practice. As outlined here, there are a number of diagnostic tools and procedural options to minimize the risk for nerve injury after third molar removal. Timely management of nerve injuries is linked to proper evaluation and documentation of neurosensory function and referral to a clinician (eg, oral and maxillofacial surgeon or other) with microneurosurgical training.

Increased tendency to temporary nerve damage with lingual retractor use

Question: Does use of lingual retractor increase risk of nerve damage in third molar retraction? Objective To review the incidence and recovery of lingual nerve damage after the removal of the third molar by three different techniques.Data sources Medline, Health Star, Current Contents, Allied and Alternative Medicine, Life Sciences, Web of Science, Nursing Allied Health and the Cochrane library, up to May 1999. The index of the Journal of Oral and Maxillofacial Surgery Clinics of North America 1989–1998 was also searched together with the bibliographies of identified studies.Study selection Original cases of lingual nerve damage due to third molar removal with >6 months follow-up and clinically objective sensory testing. Three different surgical methods were evaluated: buccal approach with lingual retraction (BA+), buccal approach without lingual retraction (BA−) and lingual split technique (LS).Results Although 51 studies addressed the issue of lingual nerve damage only eight met the inclusion criteria. All comparisons of temporary nerve injury rates between the three surgical groups were significant (P<0.001). A summary of the results is presented below (Table 1).Conclusion The current literature does not show or support any significant advantage for the use of a lingual flap retractor to protect the lingual nerve during third molar surgery. It does show an increased tendency for temporary injury, however.

In reply

We would like to thank Dr Üçok for his careful reading of our article. The omission of the article he cites in the letter demonstrates one of the limitations of systematic reviews. Computer database searches are used to identify articles for inclusion in these reviews. Because we were evaluating lingual nerve and third molars, these words, as well as the other combinations outlined in our review, were linked together for the search. If the individual indexing an article for the computer database does not include both terms, the article will not be found when searching for the combination of words. In fact, we repeated the search using the combinations of words and did not find the article. The article is cited when morbidity and third molars are used in combination. Because the combination of morbidity and third molars produced so many citations of unrelated articles, we decided not to use the combination. It is not surprising that the article was not found through use of our search methods. The title of the manuscript does not include comments related to sensory impairment, and the abstract does not report the incidence of sensory impairment associated with the 2 surgical techniques used to remove the third molars. In the article, the only mention of sensory function is in the last part of the last sentence in “Results,” which states, “… and no one experienced sensory impairment of the inferior alveolar or lingual nerves.” Although the article was missed, the results from the 20 patients who participated in the study do not alter the outcome of our systematic review. Temporary numbness of the lingual nerve caused by using the lingual split technique would be 9.54% instead of 9.63%, and permanent numbness would remain the same, 0.14%. Temporary numbness of the lingual nerve caused by using the buccal approach with a retractor would be 6.30% instead of 6.35%, and permanent numbness would be 0.62% instead of 0.63%. We certainly apologize for missing Dr Üçok's article and thank him for carefully reading our review and letting us know about our omission. Even though computer database searches sometimes miss an article, it is the best method currently available to systematically review the literature and find evidence to support clinical decisions. Dr Üçok's letter also gave us an opportunity to find 2 recent articles that were published after the submission of our systematic review. Gargallo-Albiol et al 1 Gargallo-Albiol Buenechea-Imaz R Gay-Escoda C. Lingual nerve protection during surgical removal of lower third molars. Int J Oral Maxillofac Surg. 2000; 29: 268-271 Abstract Full Text PDF PubMed Google Scholar reported the results of a randomized controlled trial comparing protection of the lingual nerve with and without a lingual retractor. This study meets our inclusion criteria for review and included the extraction of 300 third molars. These investigators did not find a significant difference in temporary numbness to the lingual nerve with and without the lingual retractor and no patients had permanent numbness. Adding these data to our results did not change the results of our review. The investigators found that 3 patients had numbness with the retractor and 1 patient had numbness without the retractor. A second study 2 Valmaseda-Castellon E Berini-Aytes L Gay-Escoda C. Lingual nerve damage after third lower molar surgical extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 90: 567-573 Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar reported in this Journal found greater lingual nerve damage after third molar removal with a lingual retractor than without the retractor. This was a prospective clinical study involving consecutive patients having third molars removed by various surgeons. The decision to use the lingual retractor was based on the surgeon's preference. This study does not meet our inclusion criteria and would not have been considered for detailed analysis. These 2 articles demonstrate that systematic reviews must not be based on a particular outcome but on the validity of the study. The systematic review establishes inclusion and exclusion criteria to identify the “best” evidence available. Sometimes the studies available for review are inadequate to make a definite conclusion. The current evidence for the use of a lingual retractor when removing lower third molars indicates that there is greater tendency for temporary numbness of the lingual nerve. It is unclear whether the retractor protects the lingual nerve from permanent numbness, because permanent numbness is very low for extraction done with and without the lingual retractor.

Lingual flap retraction and prevention of lingual nerve damage associated with third molar surgery: A systematic review of the literature

Objective: Lingual nerve damage sometimes occurs after the removal of third molars. The use of a lingual retractor has been advocated to protect the lingual nerve. A systematic review of the literature was undertaken to evaluate the incidence of lingual nerve damage after third molar surgery and the effect of a lingual retractor on nerve damage. Study Design: An exhaustive computerized search of several databases and references cited in the various studies was performed. Predetermined inclusion and exclusion criteria were used to identify the 8 published studies acceptable for detailed analysis. The incidence and spontaneous recovery of lingual nerve injury for the following 3 surgical techniques were evaluated: the buccal approach with lingual flap retraction (BA+), or the buccal approach without lingual flap retraction (BA–), and the lingual split technique with lingual flap retraction (LS). Results: In the 8 selected articles, lingual nerve injury occurred in 9.6%, 6.4%, and 0.6% of the pooled LS, BA+, and BA– procedures, respectively. On the basis of risk ratios comparing combined incidence rates, lingual nerve injury is 8.8 times more likely to occur in BA+ than in BA– procedures (CI = 4.3-17.8), 13.3 times more likely to occur in LS than in BA– procedures (CI = 6.6-26.9), and 1.5 times more likely to occur in LS than in BA+ procedures (CI = 1.2-1.8). Permanent lingual nerve injury occurred in 0.1%, 0.6%, and 0.2% of the combined LS, BA+, and BA– procedures, respectively. The combined permanent incidence risk ratios were not calculated because of the low permanent incidence rates. Conclusions: The use of a lingual nerve retractor during third molar surgery was associated with an increased incidence of temporary nerve damage and was neither protective nor detrimental with respect to the incidence of permanent nerve damage. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:395-401)

Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques

Purpose: This study compared swelling, pain, and trismus after using the conventional buccal approach and the lingual split technique for the removal of impacted third molars. Materials and Methods: Twenty patients with a mean age of 21.5 years were included. Postoperative edema was followed stereophotogrammetrically for 48 hours by transferring photogrammetric data from three-dimensional profile views into orthographic maps. A visual analog scale was used for 6 days for determining pain. Mouth opening was measured on the 1st, 2nd, and 7th postoperative days. Results: Maximal swelling was noted in both groups on the second postoperative day. In both groups, maximal trismus was noted on the first postoperative day. Approximately 98% of the measurements of interincisal distances had returned to the preoperative values by the 7th day. There was no significnt difference in the pain intensity between the two groups on postoperative days 1 through 6. Swelling ( P = .88) and pain ( P = .12) were not significantly different in either groups. Trismus was found to be significantly less ( P = .03) in the lingual split group. Conclusion: Although swelling and pain were comparable in both groups, the amount of trismus was less with the lingual split technique. This may be an advantage of the latter technique.

Lingual split technique. Damage to inferior alveolar and lingual nerves during removal of impacted mandibular third molars.

Lingual split technique. Damage to inferior alveolar and lingual nerves during removal of impacted mandibular third molars