VOLUME 43 NUMBEP 5 MAY 2012 353

QUI NTESSENCE I NTERNATI ONAL

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. The paresthesia disappears
within 2 to 4 weeks, after the clot is orga-
nizod.
Tno ibrous roorganization o tno olot
can sometimes be the premise for a nerve
orusn, wnon it nappons, parostnosia arisos
in 2 to 4 weeks and disappears within a few
months.
During olot roorganization, it oould bo
possible that bone fragments damaged
during tno oxtraotion o tno tootn could
affect tno norvo, rosulting in dolayod paros-
thesia that appears after a few months and
disappears in a few weeks.
A suggestion in the clinical practice is to
prooood as ollows:
Perform saline irrigation.
Pomovo tno bono ragmonts making an
ostooplasty.
Perform a surgical debridement of the
alveolar socket.
Use collagen sponges to protect the
norvo and roduoo tno possibility o in|ury
in oasos o norvo oxposuro.
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