Nerve: A Review
Somsak Sittitavornwong, DDS, DMD, MS,* Michael Babston, DMD, MD,y
Douglas Denson, DMD, MD,z Steven Zehren, PhD,x and Jonathan Friend, MSk
Purpose: Knowledge of lingual nerve anatomy is of paramount importance to dental practitioners and
maxillofacial surgeons. The purpose of this article is to review lingual nerve anatomy from the cranial base
to its insertion in the tongue and provide a more detailed explanation of its course to prevent procedural
nerve injuries.
Materials and Methods: Fifteen human cadavers from the University of Alabama at Birmingham School
of Medicines Anatomical Donor Program were reviewed. The anatomic structures and landmarks
were identified and confirmed by anatomists. Lingual nerve dissection was carried out and reviewed on
15 halved human cadaver skulls (total specimens, 28).
Results: Cadaveric dissection provides a detailed examination of the lingual nerve from the cranial base
to tongue insertion. The lingual nerve receives the chorda tympani nerve approximately 1 cm below the
bifurcation of the lingual and inferior alveolar nerves. The pathway of the lingual nerve is in contact with
the periosteum of the mandible just behind the internal oblique ridge. The lingual nerve crosses the
submandibular duct at the interproximal space between the mandibular first and second molars. The sub-
mandibular ganglion is suspended from the lingual nerve at the distal area of the second mandibular molar.
Conclusion: A zoning classification is another way to more accurately describe the lingual nerve based
on close anatomic landmarks as seen in human cadaveric specimens. This system could identify particular
areas of interest that might be at greater procedural risk.
Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial
Surgeons
J Oral Maxillofac Surg 75:926.e1-926.e9, 2017
The mandibular division of the trigeminal nerve is a during routine oral surgical procedures, including
sensory and motor nerve descending through the inferior alveolar nerve block injection, lingual flap
foramen ovale. It carries general sensory branches retraction, and third molar removal.3-11 The aim of
to the oral cavity, face, and ears. The course of the this study was to further break down the lingual
lingual nerve from the cranial base to its insertion nerve into zones based on anatomic landmarks.
into the tongue has been well described.1,2 Given the variability of the position of the lingual
However, this well-known pathway does not seem nerve from person to person, a detailed description
to prevent lingual nerve injury during head and of its average descent from the cranial base to the
neck surgery, specifically as it relates to oral and tongue and surrounding anatomic structures in
maxillofacial surgery. Multiple studies have cited each zone could provide the clinician with more
the incidence of lingual nerve injury encountered information to avoid injuring the nerve.
Received from the University of Alabama at Birmingham, Address correspondence and reprint requests to Dr Sittitavorn-
Birmingham, AL. wong: Department of Oral and Maxillofacial Surgery, University of
*Associate Professor, Department of Oral and Maxillofacial Alabama at Birmingham, 419 School of Dentistry Building, 1919
Surgery. 7th Avenue South, Birmingham, AL 35294-0007; e-mail: sjade@uab.
yResident, Department of Oral and Maxillofacial Surgery. edu
zResident, Department of Oral and Maxillofacial Surgery. Received September 7 2016
xProfessor, Cell, Development and Integrative Biology. Accepted January 10 2017
kProgram Coordinator, Gross Anatomy Laboratory and Surgical Published by Elsevier Inc on behalf of the American Association of Oral and
Laboratory. Maxillofacial Surgeons
Conflict of Interest Disclosures: None of the authors have any 0278-2391/17/30078-2
relevant financial relationship(s) with a commercial interest. http://dx.doi.org/10.1016/j.joms.2017.01.009
926.e1
SITTITAVORNWONG ET AL 926.e2
FIGURE 1. Medial view of the mandibular branch of the trigeminal nerve and the maxillary artery.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e3 CLINICAL ANATOMY OF THE LINGUAL NERVE
FIGURE 2. The lingual nerve is approximately 1 cm in front of the mandibular foramen. a, Distance from the lingual nerve to the lingula of the
mandible; asterisk, lingula of the mandible.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
The lingual nerve passes downward between the The lingual nerve makes a turn in an anteromedial
ramus of the mandible and the medial pterygoid direction at the posterior attachment of the mylohyoid
muscle, crossing the muscle approximately one muscle to the mandible (Fig 5). The lingual nerve en-
third the distance from its origin to its insertion ters the mouth by passing beneath the lower border
(Fig 3). From the medial view, the lingual nerve of the superior constrictor muscle. At this point, the
courses behind the medial pterygoid muscle and nerve is below and behind the third molar. It is usually
re-emerges at the anterior border. As it passes down- in contact with the periosteum of the mandible or the
ward, the lingual nerve is in contact with the perios- upper surface of the mylohyoid. The lingual nerve
teum of the mandible and is posteroinferior to the courses anteriorly just superior to the mylohyoid
internal oblique ridge and parallel to the anterior muscle within the floor of the mouth. The lingual
border of the mandibular ramus (Fig 4). nerve can be found between the sublingual and
FIGURE 3. Medial view shows the lingual nerve crossing the medial pterygoid muscle approximately one third the distance from its origin to its
insertion.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e4
FIGURE 4. Medial view shows the lingual nerve in contact with the periosteum of the mandible just behind the internal oblique ridge.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
submandibular glands. At the distal aspect of the the mouth above the submandibular gland and below
mandibular second molar, the submandibular ganglion the lingual nerve.
can be found connected inferiorly to the lingual nerve The lingual nerve descends in an arch to the
(Fig 6). The submandibular ganglion is in the floor of inferior surface of the tongue. It loops around the
FIGURE 5. Medial view shows the lingual nerve coursing anteriorly just superior to the mylohyoid muscle.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e5 CLINICAL ANATOMY OF THE LINGUAL NERVE
FIGURE 6. Medial view shows the submandibular ganglion suspended from the lingual nerve at the distal area of the second mandibular
molar.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
submandibular duct laterally and medially before sup- nerves. To more specifically describe the lingual
plying sensory fibers to the anterior two thirds of the nerve, the authors propose a new description based
tongue (Fig 7). on anatomic zones (Fig 8). The goal is to aid in iden-
tifying potential cases at high risk for lingual nerve
injury. In those cases with existing nerve injury, it
Discussion
can aid in the identification of the level of injury, pro-
After the mandibular division of the trigeminal vide diagnostic information that might aid in surgical
nerve passes through the foramen ovale, it subdivides repair, and help establish a prognostic index.
further into several sensory and motor branches. A description of these zones is provided (Fig 9).
Among these are the inferior alveolar and lingual Zone 1 extends from the skull base superiorly to the
FIGURE 7. Medial view shows the lingual nerve coursing anteriorly and crossing the submandibular duct at the interproximal space between
the mandibular first and second molars.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e6
FIGURE 9. Zone 1 is the lingual nerve pathway from the skull base to the lingula, zone 2 is the lingual nerve pathway from the lingula to the
junction of the internal oblique ridge and mylohyoid line (plus sign), and zone 3 is the lingual nerve pathway from the junction of the internal
oblique ridge and mylohyoid line to the peripheral nerve end supplying the tongue. Asterisk, lingula of the mandible.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e7 CLINICAL ANATOMY OF THE LINGUAL NERVE
FIGURE 10. The submandibular ganglion is usually located at the distal area of the mandibular second molar. #, Crossing location of the
submandibular duct and lingual nerve.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
many of the authors dissections. Erdogmus et al1 from an inferior alveolar nerve injection; incision,
reported 4 furcation patterns of the lingual and the intubation, and general anesthesia; lingual flap
inferior alveolar nerves based on their positions. A retraction; bone removal and instrumentation; tooth
type I bifurcation was described as above the level of sectioning; tooth elevation; and suturing.5,6 The
the mandibular notch and was observed in 66.7% of lingual nerve has been found 10 to 17.6% of the time
specimens (Fig 9).1 at the level of the alveolar crest or higher at the
Extraction of mandibular third molars is one of the mandibular third molar.17-19 Kiesselbach and
most frequently performed procedures in oral and Chamberlain17 reported the lingual nerve contacted
maxillofacial surgery. The reported prevalence of dam- the lingual plate of the third molar in 62% of 256 pa-
age to the lingual nerve varies from almost 0 to 23%.3,4 tients. The vertical path of the internal oblique ridge
The etiologic factors of lingual nerve damage in curves horizontally at the retromolar area. At this re-
mandibular third molar surgery could be trauma gion, Pogrel et al18 reported the mean vertical distance
FIGURE 11. The submandibular duct courses anteromedially superior to the mylohyoid muscle. #, Crossing location of the submandibular duct
and lingual nerve.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e8
from the crest of the lingual plate was 8.32 mm and the at the interproximal space between the mandibular
closest distance of the nerve to the lingual aspect of first and second molars (Figs 7, 10, 11).
mandible was 3.45 mm (range, 1 to 7 mm). These find- Limitations to the study relate to demographics and
ings would help clinicians avoid lingual nerve damage technique. All cadaveric specimens were at least
during surgery. These results document the vulnera- 67 years of age. Younger specimens might offer slightly
bility of the lingual nerve as it passes medially to the different quantitative results. In addition to age, all
mandibular third molar. specimens were Caucasian.
The incidence of lingual nerve damage after For technique, 5 investigators performed the dissec-
third molar removal has been reported at 0.2 to tions. Clinical measurements were calibrated but sub-
1.6%.7-10,20,21 Lingual flap elevation and retraction, ject to subtle variation because of the nature of
which engages the internal oblique ridge, with a dissection out of the fascial planes. The major limita-
broad retractor might be a suitable technique to tion of the study is disturbance of the native anatomic
remove the lower third molars. However, the lingual course of the nerve from disruption of fascial planes
elevator and retractor can be placed or migrate too during dissection.
deeply. They can go down far enough to affect the Thorough knowledge of lingual nerve anatomy is of
lingual nerve. Baqain et al22 reported patients were critical importance to all practitioners performing
23 times more likely to sustain transient neurosensory procedures in the oral cavity. The zoning classification
damage to the lingual nerve when lingual tissues were offered by this article can aid in identification,
retracted, and they had a 7 times greater risk with diagnosis, treatment, and prognosis of lingual nerve
major bleeding into the socket during surgery. The aberration and pathology.
retraction of the lingual flap can cause injury to the
lingual nerve. The literature reports temporary lingual
nerve deficit of 1.6 to 9.1%.22-24 References
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