were described, but perforation is difficult to confirm unless cross-sectional imaging is used. 3 AN in|ury oan bo oausod by oxtraotion of the mandibular third molars, 49 implant placement, 1013 endodontic treatment of mandibular molars and premolars, (such as ovorilling or apioal surgory), 14,15 local inootions (ostoomyolitis or poriapioal or pori-implant inootions), 16 traumatic man- dibular fractures and their treatment with rigid intornal ixation, 17 ortnognatnio surgory (suon as sagittal split ostootomy), 18,19 patho- logio oxpansilo losions (suon as oysts and bonign and malignant tumors) o tno ramus and body o tno mandiblo and tnoir oxoi- sion (rosootion), 20,21 metastatic lesions to the mandible, 22,23 and local anesthesia. 24,25
Ator an AN in|ury, tno onsot o altorod sonsation usually bogins immodiatoly ator surgory, on otnor oooasions, tnougn, it bogins ator a numbor o days. The aim of this article is to evaluate tno otiology o AN dolayod parostnosia, analyzing tno litoraturo, prosonting a oaso series related to the three different inflam- matory oausos o tnis patnology, and oom- paring dolayod parostnosia 26 to immediate paresthesia. 27 n|ury o tno inorior alvoolar norvo sus- tained during removal of mandibular third molars is among the most common causes o litigation in dontistry. 1,2 One of the risk factors for inferior alveo- lar norvo (AN) in|ury ollowing mandibular tnird molar surgory is tno proximity o tno roots to tno inorior oanal (DC). Tnis oaturo is idontiiod by tnroo radiologio oaturos: diversion of the canal, darkening of the root, and interruption of the canal walls. It oan bo rooognizod by moans o poriapi- cal and panoramic radiographs. Previous roports o tnird molar pororation by tno DC 1 Clinical Assistant Professor, School of Oral Surgery, Milan University, Milan, Italy. 2 Resident, Department of Oral Surgery, Fondazione IRCCS C Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. 3 Trainee, School of Oral Surgery, Fondazione IRCCS C Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. 4 Professor and Chair, School of Oral Surgery, University of Milan, Milan, Italy; Head of Department of Implantology, Fondazione IRCCS C Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy. Correspondence: Dr Andrea Marchetti, Department of Oral Surgery, Milan University, Via Commenda, Milano 20122, Italy. Email: a.marchetti@studiomarchetti.so.it An uncommon clinical feature of IAN injury after third molar removal: A delayed paresthesia case series and literature review Andrea Borgonovo, MD, DMD 1 /Albino Bianoni, DDS 2 / Androa Maronotti, DDS 3 /Paonolo Consi, DDS 2 / Carlo Maiorana, MD, DDS 4 Ator an inorior alvoolar norvo (AN) in|ury, tno onsot o altorod sonsation usually bogins immodiatoly ator surgory. Howovor, it somotimos bogins ator sovoral days, wnion is referred to as delayed paresthesia. The authors considered three different etiologies tnat likoly produoo inlammation along tno norvo trunk and oauso dolayod parostnosia: oomprossion o tno olot, ibrous roorganization o tno olot, and norvo trauma oausod by bono ragmonts during olot organization. Tno aim o tnis artiolo was to ovaluato tno otiology o AN dolayod parostnosia, analyzo tno litoraturo, prosont a oaso sorios rolatod to tnroo dioront oausos o tnis patnology, and oomparo dolayod parostnosia witn tno olassio immodiato symptomatio parostnosia. (Quintessence Int 2012;43:353359) Key words: dolayod parostnosia, AN, inorior alvoolar norvo, norvo oxposuro, third molar, wisdom tooth 354 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Borgonovo et al CASE 1 A 24-yoar-old woman witn oooasional dis- comfort from her mandibular right third molar came to the Department of Oral Surgory, Dontal Clinio, PCCS C Granda, Ospedale Maggiore, Policlinico di Milano, Milan, taly, prosonting witn an impaotod mandibular right third molar. According to tno Poll and Grogory olassiioation, 28 it was in a Class 2B mosioangular position. Examining tno panoramio radiograpn, tno norvo soomod to run intorradioularly between the distal root and the two mesial roots and intraradioularly botwoon tno two mesial roots, presenting an entrapment (Fig 1). Tno tootn was oxtraotod undor looal anesthesia using Optocain 30 mg/mL with- out epinephrine and plessic anesthesia using Optocain 20 mg/mL with epinephrine 1:100,000, after raising a mucoperiosteal lap oxposing tno bono plato and doing an ostootomy around tno orown o tno tootn. A mesial crown resection was then per- formed, and a root separation was carried out (Fig 2). Ator surgory, tno pationt did not roport sonsitivity altorations in tno AN aroa. Fivo days ator surgory, tno pationt roturnod witn an altoration o sonsitivity o the right side of the chin and lower lip. A parostnosia o tno AN was supposod as a possible consequence of the mandibular rignt tnird molar oxtraotion. Sinoo tno parostnosia bogan a ow days ator surgory and spontanoously disap- poarod witnin 2 wooks, dolayod parostnosia was supposod, probably duo to oompros- sion of the nerve from the clot. In fact, bleeding in the postoperative period could put prossuro on tno AN, oausing an altora- tion in sensation. After some weeks, the clot would dissipato, tnoroby rolioving any pros- sure on the nerve. 29,30 CASE 2 A 31-yoar-old man prosontod witn oooa- sional discomfort from his mandibular third molar. Ho undorwont radiographic evalua- tion that revealed an impacted mandibular right third molar. According to the Pell and Grogory olassiioation, it was in a Class 2B mosioangular position (Fig 3). Surgory was plannod. Ator adminis- trating local anesthesia, a mucoperiosteal flap was raisod, and an ostootomy was performed around the crown of the tooth. A distal ooronootomy was porormod, and tno tootn was oxtraotod by tno uso o a lovor and oalipor (Figs 4 and 5). Postsurgory, tno pationt did not roport any altorations to sonsitivity. Fig1 Radiograph of the course of the IAN. Fig 2 Exposed IAN. VOLUME 43 NUMBEP 5 MAY 2012 355 QUI NTESSENCE I NTERNATI ONAL Borgonovo et al Four wooks ator surgory, tno pationt returned, presenting an alteration of sensi- tivity at tno rignt sido o tno onin and lowor lip. Parostnosia o tno AN was supposod as a possible consequence of the impacted mandibular rignt tnird molar oxtraotion. t was oonsidorod a dolayod parostnosia o tno AN booauso o its dolayod prosonta- tion and spontaneous disappearance after 6 months. The healing of the socket might result in the formation of fibrous scar tissue that could involvo tno AN, witn a lato prossuro ooot on the nerve causing an alteration in sensation. t bogins sovoral wooks ator oxtraotion and needs a few months to resolve itself. 31 Booauso o its timing and onaraotoris- tics, tnis olinioal situation was probably duo to tno oomprossion o tno norvo oausod by a ibrous roorganization o tno olot. Fig 3 CT scan showing the relation- ship between the root and the nerve. Fig 4 IAN exposed. Fig 5 Root showing IAN passage. 356 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Borgonovo et al CASE 3 A 38-yoar-old woman prosontod witn oooa- sional discomfort from her impacted man- dibular rignt tnird molar. t was norizontally inclined in a Class 2C position (Figs 6 and 7), aooording to tno Poll and Grogory olas- sification. Tno tootn was oxtraotod undor looal anesthesia, after raising a mucoperiosteal lap, oxposing tno bono plato, and doing an ostootomy around tno orown o tno tootn. A mesial crown resection was performed, and a root separation was carried out (Fig 8). Ono wook ator surgory, tno pationt roturnod witn an altoration o sonsitivity at the right side of the chin and lower lip. The situation spontanoously rosolvod itsol 2 months later. A parostnosia o tno AN was at irst sup- posed as a consequence of the impacted mandibular rignt tnird molar oxtraotion. n oomplioatod oxtraotions suon as tnis one, microfractures in the bone could occur, and fragments of bone could remain within tno sookot. Tnus, in tno oarly postoporativo period, vigorous movements could cause displacement of these microfragments that oould put prossuro on tno AN. 32 n tnis oaso, tno diagnosis o a dolayod parostnosia o tno AN, because of its timing and characteristics, was ascribed to trauma oausod by bono ragmonts in|uring tno norvo during tno roorganization o tno olot. Fig 6 Panoramic radiograph. Fig 7 CT scan showing the relationship between the root and the nerve. Fig 8 IAN exposed. VOLUME 43 NUMBEP 5 MAY 2012 357 QUI NTESSENCE I NTERNATI ONAL Borgonovo et al DISCUSSION Most mandibular third molars are not inti- matoly rolatod to tno AN oourso 33,34 and may bo saoly romovod witnout oausing any in|ury to tno norvo. Wnonovor oontaot oxists, special informed consent must be given by tno pationt booro surgory. 35 It is estimated that the incidence of per- foration is 1 in 800 impactions. 36 To predict tnis ovontuality, Howo and Poyton, in a largo rotrospootivo study o 1,355 tnird molars, 37
suggested three radiographic signs of per- oration: a radioluoont band orossing tno root abovo tno apox, a loss o botn radiopaquo borders of the canal where it crosses the root, and a constriction of the canal in the middlo o tno root. Tnoy ound tnat 38% of tootn displayod loss o botn oanal tramlinos, 11% had loss of the superior tramline, 5% had narrowing of the canal, and 9% showed no spooiio oaturos. Wnon tno wnito linos o tno oanal aro unbrokon, it is unlikoly tnat any grooving or pororation is prosont. Tno white lines are lost when the borders of the oanal aro onoroaonod upon by tno tootn. 26
Therefore, in cases of perforation, both white lines would be lost. In cases where tno apox is groovod by only tno oanal, tno superior line is lost and the inferior line remains intact. A method proposed to man- ago tnoso oasos is ooronootomy, 3841 since it nolps to provont damago to tno AN. Poot raoturo during oxtraotion o tnird molars ooours witn an inoidonoo o approximatoly 3% to 4.9%. 27,42 Padiograpnio viows obtainod witn pori- apical, panoramic, and oblique lateral radiographs are often requested to show impacted third molars. n oasos o dooply impaotod mandibular third molars, a sagittal split ramus osteoto- my oould bo usod to romovo tnom. n aot, the main disadvantages of conventional oporations or suon tootn aro tno oxtont o bono romovod, limitod visibility, nign risk o in|ury to tno inorior alvoolar norvo, and rao- ture of the mandible. In comparison, sagittal split ramus ostootomy givos good aoooss, conserves bone that would otherwise have been removed, and allows the nerve to be seen and avoided. 4345 Tno outoomo o surgory is to a groat oxtont dopondont on tno skill and toonniquo of the surgeon. The most consistent predic- tors o norvo in|ury risk in tnird molar surgory appear to be older patients and features of oloso proximity botwoon tno tnird molar and AN, spooiioally radiograpnio signs and deep impactions. The visual sighting of an intaot AN during tnird molar surgory indi- cates that third molar is in intimate relation- snip witn tno AN and oarrios about a 20% risk of subsequent paresthesia, with a range o approximatoly 15% to 25% (95% C |oon- idonoo intorval]). Tno inoidonoo o sonsory altoration ator oxposuro o tno intaot AN, oonirmod by an abnormal nourosonsory tost rosult, was 15%. Approximatoly 60% o oasos may bo oxpootod to rooovor ator 3 months, 65% recover within 6 months, and 70% rooovor by 1 yoar ator surgory. Sonsory altoration tnat ails to rosolvo ator 1 yoar is moro likoly to porsist, altnougn gradual rooovory is still possiblo. 46 According to Tolstunov and Pogrel, 47
tno dolayod onsot o AN involvomont ator oxtraotion o a mandibular tnird molar mignt inoludo oarly postoporativo inootion, blood- ing in the postoperative period, barotrauma oausod by tno rolativo doprossurization o lying, miororaoturos and bono ragmonts, and the formation of fibrous scar tissue. The biggest difference between classic parostnosia and dolayod parostnosia is tnat tno ormor bogins immodiatoly ator tno sur- gory and noaling is not guaranteed, while the latter ooours lator but tnoro is always restitutio ad integrum. Immediate paresthesia could be caused dirootly by tno noodlo usod or tno anos- tnosia or by tno rubbing o tno roots on tno norvo and indirootly by tno luxation o tno tootn. t is immodiatoly olinioally approoi- ated because the patient will report a lack o sonsitivity in tno distriot o tno damagod nerves innervation. Soddon 48 introduced a classification of poripnoral norvo in|urios into tnroo grados. Sundorland 49 considered five degrees of in|ury, tno irst tnroo ooinoido witn tnoso o Soddon, wnilo tno ourtn and itn losions aro rolatod to in|urios o tno porinourium as well as the epineurium. 49 Evon i tnoro aro otnor oausos o dolayod parostnosia (suon as oarly postoporativo 358 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Borgonovo et al infection 50 or barotrauma oausod by tno rola- tivo doprossurization o lying at altitudo 51,52 ), the authors considered three different eti- ologios or a dolayod parostnosia during tnis oaso sorios: tno irst oausod by tno compression of the clot, the second caused by tno ibrous roorganization o tno olot, and tno tnird oausod by norvo trauma rosulting rom bono ragmonts during tno organiza- tion of the clot. All three promote inflamma- tion onset along the nerve trunk. Wnon oomprossing tno norvo, tno olot oausos a dolayod paresthesia within a few days, |ust tno timo noodod or tno olot to become solid. 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