Vol. 99 No.

3 March 2005

ORAL AND MAXILLOFACIAL SURGERY Editor: James R. Hupp

Incidence and evolution of inferior alveolar nerve lesions following

lower third molar extraction
Elena Queral-Godoy, DDS,a Eduard Valmaseda-Castellón, DDS, PhD,b
Leonardo Berini-Aytés, DDS, MD, PhD,c and Cosme Gay-Escoda, DDS, MD, PhD,d
Barcelona, Spain
UNIVERSITY OF BARCELONA AND TEKNON MEDICAL CENTER

Objectives. To calculate the incidence of inferior alveolar nerve (IAN) damage due to lower third molar extraction and to
describe the evolution of IAN sensitivity and the prognosis of IAN damage based on preoperative data.
Study design. A retrospective study of 4995 lower third molar extractions in 3513 outpatients.
Results. Fifty-five extractions (1.1%) resulted in IAN impairment. Cox regression analysis showed age to be a risk factor for the
persistence of IAN injury due to lower third molar extraction. The sensation recovery rate was higher in the first 3 months. Fifty
percent of the patients showed full recovery after 6 months.
Conclusions. Most cases of IAN impairment following lower third molar extraction recover within 6 months, though in some
cases recovery takes more than 1 year. Older patients are at an increased risk of incomplete recovery of chin and lip sensibility
after third molar extraction.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:259-64)

Damage to the inferior alveolar nerve (IAN) is a severe
complication of lower third molar extraction. Although
some radiological signs are associated with IAN
impairment, their positive predictive value is low, since
IAN injury is a rare complication.1,2
The incidence of permanent damage to the IAN after
third molar extraction is well under 1%.3-6 Few detailed
data are available on the recovery rate and risk factors
associated with permanent, rather than transient, nerve
injury.
The principal aim of this study is to calculate the
incidence of IAN injury following lower third molar
extraction in outpatients. In addition, a description is
made of the timing of sensory recovery, with quan-
tification of the effect of preoperative variables on
recovery, based on survival analysis.

a
Fellow of the Master of Oral Surgery and Implantology, School of
Dentistry of the University of Barcelona, Spain.
b All extractions of any lower third molar in outpatients
Associate Professor of Oral Surgery, Professor of the Master of Oral
Surgery and Implantology, School of Dentistry of the University of
Barcelona, Spain.
c
Professor of Oral and Maxillofacial Surgery, Professor of the
Master of Oral Surgery and Implantology, School of Dentistry of
the University of Barcelona, Spain.
d
Chairman of Oral and Maxillofacial Surgery, Director of the
Master of Oral Surgery and Implantology, School of Dentistry of
the University of Barcelona and Oral and Maxillofacial Surgeon
of the Teknon Medical Center, Barcelona, Spain.
Received for publication Feb 17, 2004; returned for revision Apr 21,
2004; accepted for publication Jun 2, 2004.
Available online 23 August 2004.
1079-2104/$ - see front matter
Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.tripleo.2004.06.001
METHODS
were included in the study. There were no exclusion
criteria. A total of 3513 outpatients underwent 4995
lower third molar extractions in the Department of Oral
and Maxillofacial Surgery (University of Barcelona,
Spain) between January 1998 and September 2001. Of
these patients, 1482 were operated on bilaterally, though
spacing the operations by at least 3 weeks. Extraction
was performed under local anesthesia. The surgical tech-
nique used was similar to that described by Leonard.7
The surgeon raised a buccal mucoperiosteal flap, which
was protected by a Minnesota retractor. Lingual flap
retraction was then carried out using an Obwegeser
periosteal elevator or a Freer periosteal elevator only

259

260 Queral-Godoy et al
Table I. Difficulty rating of third molar extractions*
Angle Mesioangular
Horizontal/transverse
Vertical
Distoangular
Depth Level A
Level B
Level C
Space Class I
Class II
Class III
*Difficulty rating based on the Winter10 and Pell and Gregory9
classifications. The column at right shows the difficulty scores. For
instance, a vertical third molar with level A and class III would have
a difficulty rating of 7 (3+1+3).
when considered necessary by the surgeon. Sterile
low-speed handpieces and sterile saline solution were
used for ostectomy and crown sectioning where necessary.
The wound was closed with 3-0 silk or catgut suture.
Antibiotic and nonsteroidal antiinflammatory medica-
tion was prescribed (usually amoxicillin 750 mg orally
3 times daily for 4 or 7 days, and sodium diclofenac
50 mg po 3 times daily for 4 or 7 days), with 0.12%
chlorhexidine digluconate rinses 3 times a day for 15
days.
The sutures were removed after 7 days, and the
patients were questioned about lower chin and lip
sensitivity. Ninety extractions (1.8 %) could not be
followed up because patients did not come for suture
removal. In cases presenting sensory impairment in the
distribution of the IAN, the affected area was mapped
and 2-point discrimination, pin-prick, and light touch
were assessed. Two-point discrimination was done with
a caliper. Pin-prick sensation was explored with a probe
and light touch with a small cotton swab. The unaffected
side was used as a control. The lesion was classified
as one of the following: dysesthesia (painful sensation
triggered by non-noxious stimuli), hypoesthesia, or
anesthesia (diminished sensation). The criteria were
based on objective testing and subjective sensation of
the patient. Lesions were monitored at least after 15
days and after 1, 3, and 6 months. The patient was then
followed up every 6 months. At every follow-up visit the
lesion was objectively tested and the patient reported
subjective sensations. The lesion was considered to be
recovered if the patient did not feel impairment of
sensation and the objective tests returned to normality.
No patients were subjected to nerve repair surgery.
The following data were collected from the clinical
records of the patients with IAN impairment: age,
gender, operated site, Nolla’s stage for the third
molar,8 classification according to the Pell and
Gregory9 and Winter10 classifications, difficulty rating
(Table I), degree of inclusion (erupted, mucosal re-
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March 2005
tention, or bone retention), time to recovery or the last
1
follow-up visit if recovery did not take place, and
2 surgical technique (ostectomy or tooth sectioning). Nine
3 patients had removed the panoramic radiographs from
4 their clinical records, and radiological information such
1 as Nolla’s stage, the Pell and Gregory and Winter
2 classifications, and the difficulty rating could therefore
3 not be gathered.
1 Patients with incomplete follow-up (less than 1 year
2 without recovery) were considered dropouts. The differ-
3 ence in the former variables between dropouts and com-
plete follow-ups were assessed with Mann-Whitney U
and chi-square tests. The level of significance was set
at .05.
Statistical analysis and modeling were done using the
Statistical Package for the Social Sciences (SPSS 9.0).
A Kaplan-Meier analysis of survival was performed to
calculate the recovery rate across time. The life tables
and the rate of recovery were calculated with the
actuarial method.
A Cox regression was developed, using a stepwise
backward procedure, based on the change in likelihood
ratio (LR). The dependent variable was the time elapsed
until recovery or the last follow-up visit (if recovery did
not take place), and the covariates were age, gender,
Nolla’s stage,8 the degree of inclusion, the Pell and
Gregory ABC and 123 classifications,9 the Winter
classification,10 the combined difficulty rating, ostec-
tomy, and tooth sectioning. Another model was devel-
oped using a stepwise forward procedure based on
the change in LR. The criteria for inclusion and ex-
clusion of a variable in the model were P \ .05 and
P [.10, respectively.
RESULTS
Fifty-five patients showed IAN alterations when the
sutures were removed. Bilateral injury was observed
in 1 case. The proportion of extractions resulting in
IAN damage was 1.1% (95% confidence interval [CI]:
0.8-1.4%). Two percent of the lesions were classified as
total anesthesia, 16% as dysesthesia, and 82% as
hypoesthesia. Patients were followed-up for a median
of 77 days (IQR = 189 days). Twenty-six patients were
lost before observing recovery, with a median follow-up
of 113 days (IQR = 190.8 days). Fifty percent of the
patients fully recovered after 6 months. Seven out of
15 patients who failed to recover after 6 months did so at
a later point in time—the longest interval to recovery
being 1.5 years. Three quarters of the patients who
recovered did so in less than 1 year.
Thirty-eight patients did not receive any treatment,
whereas 13 received a vitamin B complex once
a day—usually Nervobion po (Merck; Mollet del Vallès;
Spain)—for a median of 25.5 days (IQR = 16.3 days),
OOOOE
Volume 99, Number 3 Queral-Godoy et al 261

Table II. Pell and Gregory9 classification of third

molars. Only third molars with panoramic radiographs
available in the clinical records are represented
I II III Total
A 6 7 4 17
B 2 10 3 15
C 0 1 13 14
Total 8 18 20 46

and 5 patients underwent low-power laser sessions

(LASER 305-IRL; Eymara, Barcelona, Spain) weekly
for 7-15 weeks.
Patient age showed a non-normal distribution, with
a median of 29.8 years (IQR = 15.6 years), and a range
of 17.2-64.5 years. Nolla’s development stage showed
a non-normal distribution, with a median of 9 (IQR = 2)
and a range 6-10. Fig 1. Survival function of IAN impairments calculated with
Thirty-one patients with IAN damage had been sub- the Kaplan-Meier method. The horizontal axis represents days
jected to left lower molar extraction, whereas 25 had after surgery and the vertical axis the proportion of IAN
undergone right lower molar extraction. There were impairment. The discontinuous line represents the cumulative
proportion of impaired IAN at a given moment in time.
47 females and 8 males. The Pell and Gregory
Triangles are censored times, ie, the maximal follow-up time
classification9 is shown in Table II. Twenty-four third
of patients who were lost before observing recovery.
molars were in a mesioangular position, 15 were
vertical, 6 were horizontal, and 1 was distoangular.
Three third molars were erupted, 31 presented
mucosal impaction, and 22 were intraosseous. One
third molar was extracted conventionally without
raising a flap, whereas 2 required the raising of
a mucoperiosteal flap, 11 also required ostectomy, and
32 ostectomy and tooth sectioning. The difficulty rate
exhibited a non-normal distribution, with a median of 6
(IQR = 2) and a range of 3 to 9.
Nonrecovered patients who were followed up for less
than 1 year (dropouts) and patients who recovered or
were followed up for more than 1 year (followed-up
patients) had a similar distribution of age, Nolla’s stage,
difficulty rate, and time of follow-up (Mann-Whitney
U test, P [.05). There were no differences between
followed up patients and dropouts in terms of gender,
operated side, Pell and Gregory and Winter classi-
fications, experience of the surgeon, surgical technique,
Fig 2. Hazard function of IAN impairments calculated with
depth of the inclusion and received treatment (Chi- the Kaplan-Meier method. The horizontal axis represents days
square test, P [.05). after surgery and the vertical axis the cumulative risk of IAN
The Kaplan-Meier analysis of cumulative survival recovery. The discontinuous line represents the cumulative
is represented in Fig 1. The hazard function is shown hazard of recovery at a given moment in time. Triangles are
in Fig 2. Figs 3 and 4 in turn show the survival function censored times, ie, the maximal follow-up time of patients
and density function calculated with the actuarial who were lost before observing recovery.
method. The life table calculated with the actuarial
method is presented in Table III. where h(t;age) is the probability of recovery at a given
The final Cox regression equation included only time (t), for a given age in years, and h0(t) is a constant.
age as covariate, using both forward and backward The risk of recovery from IAN injury is multiplied by
methods: 0.96 (95% CI 0.93-0.99) with every year of age (ie,
divided by 1.04). For instance, a patient with IAN
h(t;age) = h0 (t)
eÿ0:0383
age damage who is 10 years older than another subject has

262 Queral-Godoy et al
Fig 3. Survival function calculated with the actuarial method.
The horizontal axis represents months after surgery and the
vertical axis the proportion of IAN impairments. Squares
represent the proportion of IAN impairments for a given
interval. The lower square corresponding to the 15th month
indicates the final proportion of IAN impairments after more
than 15 months.
a probability of recovering at a given time multiplied by
0.68 (eÿ0.383)(ie, divided by 1.47).
Only age was included in the model. The change in
ÿ2
LL was significant with the inclusion of this variable
(x2 = 5.795; df = 1; P = .016).
DISCUSSION
The confidence interval of the incidence of IAN
injuries after lower third molar extraction is narrower
than the confidence interval published in an earlier study
of the etiology of IAN damage (0.8-1.4% vs 0.7-2.0% in
the previous study).6 The new confidence interval of
IAN injury is within the limits of the former interval and
closer to its lower limit, probably because some of the
operations in this study were nonsurgical, whereas in the
former paper conventional extractions were excluded.
However, the risk of infradetection of IAN injuries is
greater in the present study, since the earlier survey was
prospective.
Survival analysis has not been used to date in studies
of IAN nerve recovery. Kaplan-Meier and actuarial
analysis of survival and Cox regression are very
appropriate tools for evaluating events in data with
censored times, such as the recovery of nerve damage
(ie, data that deal with patients without recovery or
‘‘lost’’ patients). The loss of patients is a serious
limitation of this study. Many patients become tired of
follow-up visits, especially if their disorders are well
tolerated, as is usually the case. As a result of such losses
to follow-up, the incidence of permanent IAN injury
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March 2005
Fig 4. Density function calculated with the actuarial method.
The horizontal axis represents months after surgery and the
vertical axis the recovery rate. The latter is seen to be very
high in the first 3 months (0.13% per month), but decreases
dramatically over the next 3 months to only 0.02% per month.
after third molar extraction can be difficult to calculate.
However, there were no preoperative factors associated
to dropouts. Lost patients had a similar distribution of
the preoperative variables, and even of the follow-up
time. So the risk of bias in using only uncensored times
does not seem to be high. Previous studies have reported
permanent injury rates of 0.4-0.9% following lower
third molar extractions.3-6 In the present study, 2 out of
56 lesions persisted for more than 2 years and were
considered to be permanent, though many lesions were
lost to follow-up before recovery. In a previous study in
which 15 patients with IAN damage were controlled
until recovery or for at least 1 year, 25% of all IAN
impairments noted after suture removal were associated
to some permanent loss of sensitivity.6
Advanced age is a risk factor for IAN injuries
after third molar extraction6,11 and mandibular
osteotomies.12-16 However, advanced age is a risk factor
for permanent IAN injuries as well.6,16 The present
study confirmed that the chances of recovery are less in
older patients, and this observation did not seem to be
biased by dropouts, as both lost and followed up patients
had a similar age distribution. This could be because
older patients suffer more severe damage or because of
decreased nerve regeneration or neuronal plasticity.
This latter hypothesis is supported by reports on the
effect of age on peripheral nerve regeneration17-22 and
by the fact that older patients, despite a macroscopically
less traumatized IAN, show poorer recovery after
mandibular osteotomies.16
The recovery rate is high in the first 3 months (0.12%
per month), but subsequently decreases, in coincidence
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Volume 99, Number 3 Queral-Godoy et al 263

Table III. Life table of inferior alveolar nerve recovery*

Patients Proportion Cumulative proportion Probability Hazard
exposed surviving of surviving (SE) density (SE) rate (SE)
0-3 months 49 0.61 0.61 (0.07) 0.13 (0.02) 0.16 (0.04)
4-6 months 21.5 0.91 0.56 (0.07) 0.02 (0.01) 0.03 (0.02)
7-9 months 14.5 0.86 0.48 (0.08) 0.03 (0.02) 0.05 (0.03)
10-12 months 9 0.67 0.32 (0.09) 0.05 (0.03) 0.13 (0.08)
13-15 months 5 0.60 0.19 (0.09) 0.04 (0.03) 0.17 (0.11)
[15 months 2 0.50 0.10 (0.08) — —
*Life table calculated with the actuarial method based on a timeframe of 15 months, subdivided into 3-month intervals. The column ‘‘patients exposed’’
represents the mean number of exposed patients at a given interval. ‘‘Proportion surviving’’ indicates the proportion of patients with IAN impairment
that continue to suffer impairment at the end of the time interval. ‘‘Cumulative proportion of surviving’’ is the cumulative representation of this same
proportion. ‘‘Probability density’’ is the rate of recovery in an interval (percentage of recoveries per month), while ‘‘hazard rate’’ is the rate of recovery
for patients who have not recovered at the beginning of an interval (percentage of recoveries per month). SE = standard error.

with the observation that the probability of recovery
beyond 6 months is very low.23 In our study almost half
of the patients with lesions persisting for more than 6
months effectively recovered, though in some cases
recovery took more than a year. The rate of recovery
increases after 6 months and again after 9 months,
exhibiting a bimodal pattern (half of the patients
recovered in less than 3 months, though after this period
patients seemed to take considerably longer to recover,
with a continuous increase in recovery rate up until
12-15 months). This could be explained by the fact that
IAN injuries differ in type. Lesions that recover within
the first 3 months are probably neurapraxias or Sunder-
land first or second degree injuries,24,25 which are
more common, and long-standing injuries could repre-
sent more severe axonotmesis or Sunderland third-
or even fourth-degree injuries. However, because of the
important number of patients lost to follow-up at 6
months, these data must be interpreted with caution.
Recovery from IAN injuries after more than 1 year
has been reported in the literature.16,26 It is difficult to
achieve early identification of injuries with a poor
prognosis, especially if damage to the nerve has not
been seen directly during surgery. Nevertheless, it seems
that compression should not cause anesthesia for more
than 4 months, and sectioning should not cause fine
touch anesthesia for more than 8 months.27 Anesthesia
without improvement after 1 month is also very likely to
leave some permanent residual impairment.3
Patients were not operated on after the injury because
the latter were not disturbing; all patients improved their
chin and lip sensation and there were no cases of
drooling or severe dysesthesia. Most permanent injuries
consisted of hypoesthesias that were quite well tolerated
by the patient.
In the present study some patients have been
treated with vitamins or low-power laser sessions, but
as treatments have not been randomly allocated
no conclusions can be drawn on the effectiveness of
these treatments. Several drugs have been evaluated
for promoting recovery from nerve injuries, including
vitamins B1, B6, and B12, this being the composition of
the vitamin B complex administered to 12 of our
patients.28 However, although these substances improve
peripheral nerve regeneration in animal models, their
effects on humans are not supported by scientific
evidence. Low-power laser therapy has been shown to
increase axonal density after IAN repair in rabbits29 and
to improve IAN regeneration after orthognathic sur-
gery,29 though further studies are needed to assess the
true efficacy of low-power laser treatments.
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Reprint requests:
Cosme Gay-Escoda, DDS, MD, PhD
Feixa Llarga s/n
Campus de Bellvitge
Pavelló Central, 2a planta
08097 - L’Hospitalet de Llobregat (Barcelona), Spain
cgay@bell.ub.es