The trigeminal nerve supplies sensation to
the mouth, face and scalp. It is the largest
sensory nerve and input is represented by
over 40% of the sensory cortex.Wisdom
teeth are placed between two large
branches of the trigeminal nerve.
The lingual nerve, supplying the anterior
tongue with sensation and taste (from
facial nerve) lies adjacent to the lingual
side of the tooth.The inferior alveolar
nerve lies adjacent to the roots of the
tooth supplying the lower teeth, gums,
lower lip and chin.
Trigeminal nerve injury, especially lingual
and inferior alveolar nerve injuries, causes
patients significant lifelong disability. As
with other surgical sensory nerve injuries,
neuropathic pain is a common complaint.
Due to the location of the injury, the
patients often complain of constant
pain in the face and/or mouth causing
significant difficulties with eating, speaking,
drinking, sleeping, kissing and difficulty
with make-up application or shaving.
These are basic social interactions we
all take for granted, hence the diabolical
effect these nerve injury complications
have on the patients involved. As with
other peripheral sensory nerve injuries,
they remain a challenge to manage either
medically or surgically and the patients
often have a lifetime of chronic pain and
disability ahead of them.Thus, prevention
is preferable to the management.
My focus has been on minimising trigeminal
nerve injuries. I have developed methods
that minimise surgical access and I have
challenged conventional practice with the
development of novel surgical techniques
that avoid trigeminal nerve injury.
We now routinely use a modified surgical
‘buccal’ approach from one side of the
wisdom tooth, thus avoiding injuries to
the lingual nerve on the medial aspect
of the mandible. Bone removal is also
reduced by careful sectioning and
implosion of the tooth to be removed.
This approach is evidence based in
reducing nerve injuries.
If the tooth is close to the inferior
alveolar nerve (Figure B), prevention
of injury is now possible using the
coronectomy technique and is now also
a recognised procedure (Figure C).
In a high volume surgical specialty, it is
extremely exciting being at the ‘cutting
edge’ of developments in preventing
BDS MDSc PhD FRACDS
FDSRCS FRACDS (OMS) ITLM
Consultant Oral Surgeon
Fig A. shows lingual nerve neuroma subsequent to third molar surgery. Fig B. shows the lower
left third molar crossing the bony canal containing the left inferior alveolar nerve. Fig C. shows
the lower left third molar two years after coronectomy procedure. Roots remain vital and
retained with no damage to the nerve.
Dentoalveolar surgery (extraction of
teeth) remains one of the most common
procedures undertaken within the NHS.
A common complication of wisdom
tooth removal is trigeminal nerve injury
(Figure A).This can be minimised using
recent developments in minimal access
surgery and with the use of novel surgical
techniques that spare the adjacent nerves.
such debilitating surgical complications.
As a specialty, we continue to evaluate
future improvements in our surgical
techniques and provide specialist clinics
for those patients unfortunate enough to
sustain these nerve injuries, enabling us
to modify their management for example,
early intervention nerve exploration.
For further information, please
020 3299 2313