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Oral Surgery

15

Minimally Invasive

Oral Surgery

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

Professor

Tara Renton

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.

Fig B.

Fig C.

Fig A.

For further information, please

contact

020 3299 2313

.