Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

ors_1096

8..14

Characteristics of patients referred to a UK trigeminal

nerve injury service
P.P. Robinson
Department of Oral and Maxillofacial Medicine and Surgery, University of Shefeld, Shefeld, UK

Key words:
inferior alveolar nerve, lingual nerve, nerve
injury, nerve repair
Correspondence to:
Professor PP Robinson
Department of Oral and Maxillofacial Medicine
and Surgery
School of Clinical Dentistry
Claremont Crescent
Shefeld S10 2TA
UK
Tel.: +44 114 271 7849
Fax: +44 114 271 7863
email: p.robinson@shefeld.ac.uk
Accepted: 27 July 2010
doi:10.1111/j.1752-248X.2010.01096.x

Abstract
Aim: Patients suffering from a persistent sensory disturbance or pain following a trigeminal nerve injury are frequently referred to a specialist
centre for evaluation. This study reports the characteristics of the patients
seen on a designated nerve injury clinic during 2008.
Methods: Information from 100 consecutive patients was collated, including
demographic details, source of referral, nerve damaged, cause of the injury,
presence or absence of dysaesthesia and nature of the treatment, if offered.
Results: There were 70 females and 30 males, with a mean age at presentation of 42 years (range 2178 years). Sixty-five per cent of referrals were
from a consultant, and patients travelled from a wide geographical distribution across England, Wales and Ireland. The delay between nerve injury and
referral ranged from 1 month to 5 years. Fifty-six per cent of the patients had
sustained an inferior alveolar nerve (IAN) injury and 44% had a lingual
nerve injury. Most injuries (59%) were caused by lower third molar removal,
but there were numerous other causes, including 10% associated with local
anaesthetic administration. A similar proportion of patients reported symptoms of dysaesthesia after lingual nerve (41%) and IAN (45%) injuries. Only
41% of patients were treated (52% of lingual nerve injuries and 32% of IAN
injuries), and this usually involved microsurgical repair (lingual nerve injuries) or decompression and neurolysis (IAN injuries).
Conclusions: The highly selected population of patients that received tertiary referral to a specialist nerve injury clinic were most commonly female
and 3050 years old. A substantial proportion had dysaesthesia, and these
patients were most likely to be offered treatment.

Clinical relevance
Rationale for study
To understand the characteristics of patients referred to
a specialist trigeminal nerve injury clinic for advice and
treatment.

Practical implications
Patients with a trigeminal nerve injury who develop
dysaesthesia or show limited signs of early recovery
should be referred to a specialist centre without delay.
Only about 40% will be deemed suitable for surgical
intervention.

Principle ndings
Patients were most commonly middle-aged females,
and more than 40% were suffering from painful
dysaesthesia. Lower third molar removal was the
commonest cause of injury.
8

Introduction
While trigeminal nerve injuries are relatively common,
experience in the management of patients who may
benefit from surgical intervention is often limited. As a
Oral Surgery 4 (2011) 814.
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Characteristics of nerve injury patients

Robinson

Materials and methods

Information was obtained relating to all patients
attending the authors trigeminal nerve injury clinic
during the calendar year 2008. Surprisingly, but conveniently, this gave data from exactly 100 consecutive
patients. All patients attending the clinic had demographic details, nerve damaged, date and cause of the
injury, symptoms, responses to specific questions and
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results of sensory testing, recorded on a pro forma.

These prospectively obtained data were combined with
information in the medical records regarding grade and
site of the referring practitioner, the delay between
initial injury and referral, and the nature of the treatment undertaken, if offered.
Particular note was taken of the proportion of patients
that were suffering from the painful symptoms of dysaesthesia (defined as an unpleasant abnormal sensation,
whether spontaneous or evoked7). This diagnosis was
based on the patients report of spontaneous or evoked
pain from the affected area, and/or evidence from
sensory tests revealing allodynia or hyperalgesia.
Details of the sensory testing protocol have been
reported elsewhere8. The outcome of the treatment
methods used has also been reported previously, so will
not be repeated here9,10.

Results
Of the 100 patients, 70 were female and 30 were male.
The age distribution was similar for females (mean age
41 years, range 2178 years) and males (mean age
42 years, range 2375 years) and is shown in Figure 1.
Referrals were received from a wide geographical distribution across England, Wales and Ireland, and the
patient locations are shown on a map in Figure 2. A
high proportion of the referrals (65%) were from a
consultant (usually an oral and maxillofacial surgeon)
with the remainder being from an SAS (Staff Grade or
Associate Specialist) grade (12%), specialist registrar
(2%), Senior House Officer (7%), General Dental
Practitioner (13%) or General Medical Practitioner
(1%). The delay between the time of injury and referral
30
25
Number of patients

result, many patients are referred to specialist centres for

advice and treatment. This article describes the characteristics of patients seen by the author in one such
centre, in Sheffield, UK, during the calendar year 2008.
The commonest cause of problematic trigeminal
nerve injury appears to be iatrogenic damage during
oral surgical procedures, such as the removal of lower
third molars. For this procedure, the incidence of
lingual nerve injury is approximately 7% (but varies
with the surgical technique employed), and the incidence of inferior alveolar nerve (IAN) injury is
approximately 4%1. In 20082009, in the National
Health Service hospital service in England alone,
68 343 third molar removals were recorded2. If we
assume that approximately two-thirds of these were
lower third molars3, the incidence of nerve injury
described above would result in over 3000 lingual nerve
injuries and nearly 2000 IAN injuries per year. Of these,
most are followed by recovery of normal sensation
within the first few weeks after the injury, but approximately 0.5% of operations1 lead to a permanent sensory
disorder (i.e. approximately 230 lingual nerve injuries
and 230 IAN injuries in England per year). Some of
these patients find the symptoms sufficiently distressing
that they seek further treatment, and this study has
determined the characteristics and specific complaints
of that group. It is important to note that the characteristics described do not represent those of the whole
population of patients that suffer a nerve injury, just
the highly selected group that have sought further help
and have pursued referral to a centre with a specialist
interest in this problem.
Others have reported observations on similar populations elsewhere. For example, Pogrel and Thamby4
reported on 163 consecutive patients attending their
unit in San Francisco, USA, and Tay and Zuniga5
described the clinical characteristics of 59 patients
referred to a university centre in Chapel Hill, USA,
over a 10 month period. A larger study by Hillerup6
described the signs, symptoms and functional status of
449 injuries seen in Copenhagen, Denmark, over an
18 year period. Comparisons will be made with observations at these other centres.

Females
Males

20
15
10
5
0

2029

3039

4049

5059

6069

7079

Age (years)

Figure 1 Age distribution: the age distribution of the 70 female and 30

male patients seen during 2008.

Characteristics of nerve injury patients

Robinson

Figure 2 Patient location: the home location of the patients, indicating the geographical spread of referrals. The number in each red dot indicates the
number of patients from that location. Map reproduced from Ordnance Survey map data by permission of the Ordnance Survey Crown copyright 2010.

to the clinic varied widely and is shown in Figure 3.

This reveals that 30% of the referrals were made within
the first 3 months after the injury, 47% within
6 months and 71% within a year, but some referrals
were delayed by as much as 5 years.
The nerves that had sustained an injury are shown in
Figure 4. In this series, 44% of patients had sustained a
lingual nerve injury and 56% had sustained an IAN
injury, and this included six patients who had an injury
to more than one nerve. Within these groups, 41% of
the lingual nerve injury patients and 45% of the IAN
injury patients had symptoms and/or signs consistent
with the diagnosis of dysaesthesia (Fig. 4). The cause
of the injury varied widely, as shown in Figure 5,
although by far, the commonest cause was the removal
10

of lower third molars (59%). Local anaesthetic administration resulted in 10% of the injuries, and mandibular implants caused 5% of the injuries. Despite the
fact that damage to the IAN commonly occurs in mandibular fractures, and the infraorbital nerve is commonly damaged in zygomatic fractures, these injuries
led to referral of only 4% and 3% of cases, respectively.
Based on previously described protocols11,12, the level
of symptoms and the anticipated outcome of surgical
intervention9,10, a decision was made on whether or not
to offer treatment. The proportion of patients with a
lingual nerve injury that proceeded to treatment was
52%, whereas the proportion with an IAN injury that
proceeded to treatment was only 32%. This difference
in part reflects the relative effectiveness of surgical
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Characteristics of nerve injury patients

Robinson

35

Number of patients

30
25
20
15
10
5
0
<3

46

79
1012 1318
Delay (months)

1924

2560

Figure 3 Referral delay: the delay between the nerve injury and referral to
the clinic.
Figure 5 The causes of the nerve injuries, showing the number of patients
in each category. #, fracture; BSSO, sagittal split osteotomy; RCT, extruded
root lling material.

Figure 4 Nerves injured: the nerves that had been injured and the proportion of patients that had developed dysaesthesia. The number of
patients with multiple injuries is shown (also included in the other
columns).

treatment of these nerves in the Sheffield unit9,10. Furthermore, treatment of an IAN injury was more likely
to be offered in the presence of dysaesthesia, and as
a result, 14 of the 17 patients who underwent IAN
decompression and neurolysis were suffering from
dysaesthesia. The types of treatment undertaken on
patients seen during 2008, and the proportion suffering
from dysaesthesia, are shown in Figure 6A and B.

graphics of patients undergoing lower third molar

removal, although this is the commonest cause of the
injury. Details of patients having third molars removed
as an inpatient in England in 200820092 show that
third molar removal was more frequently undertaken
in females (62% of procedures) than males (38%), and
the average age was 30 years. In the present study, of
the highly selected population of patients that received
tertiary referral to a specialist trigeminal nerve injury
clinic, an even higher proportion was female (70%)
and the average age was 41 years. Thus, the referred
patients were commonly middle-aged females. Similar
patterns have been seen in previous reports, with the
Chapel Hill study having 61% females and a mean age
of 40 years5, and the Copenhagen study having 73%
females and a median age of 36 years6. The report by
Pogrel and Thamby4 also found a preponderance of
females (77%) but found a lower mean age of only
28 years. While this sex distribution probably results
from females being more likely to seek treatment, there
is also some clinical evidence to suggest that a close
relationship between impacted third molars and the
mandibular canal may be more common in women13,
rendering the IAN at greater risk.

Referral

Discussion
Demographics
The patient population referred to a specialist trigeminal nerve injury clinic does not fully reflect the demoOral Surgery 4 (2011) 814.
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Most of the referred patients had been seen by their

local hospital oral surgery service initially, although
the surgery that gave rise to the nerve injury may
have been undertaken elsewhere. As a result, 65% of
the referrals were from consultants, mostly oral and
11

Characteristics of nerve injury patients

(A)

(B)

Figure 6 Treatment: the types of intervention undertaken on patients

seen during the period evaluated for (A) lingual nerve injuries and (B) inferior alveolar nerve injuries. RCT, removal of extruded root lling material.

maxillofacial surgeons. In order to obtain specialist

advice and possible treatment, patients were prepared
to travel substantial distances, emphasising the significance of the symptoms. Some of the delays before
referral were too long, even up to 5 years, and there are
many factors that could have led to these delays.
Current guidance suggests that lingual nerve or IAN
injuries resulting from third molar removal should
be monitored for approximately 3 months to assess
spontaneous recovery before deciding whether or not
surgical intervention is needed11,12,14. Should there be
little evidence of recovery by that stage, referral to a
unit with a specialist interest in the management of
trigeminal nerve injuries is appropriate.
12

Robinson

Cause of injury
In the present study, most injuries (59%) were caused
by third molar removal, with the next most common
cause being local anaesthetic administration (10%).
Very similar figures have been reported elsewhere. For
example, of 59 patients referred to a university centre
at Chapel Hill, USA, 52% resulted from lower third
molar removal, 12% from local anaesthetic injections, 12% from orthognathic surgery and 11% from
implants5. In the San Francisco study, 53% of the injuries were caused by third molar removal and 21% by
local anaesthetic administration4. Hillerup 6 confined
his study to iatrogenic injuries, but found 71% to result
from third molar surgery and 17% from local anaesthetic administration. Thus, the cause of injury seems
broadly similar in different centres evaluated in Europe
and North America.
Of the 10 injuries associated with local anaesthetic
administration in the present study, six involved the
lingual nerve and four involved the IAN; a higher likelihood of this type of damage to the lingual nerve has
been reported by Hillerup and Jensen15. These authors
also demonstrated the increased frequency of this
problem since the introduction of Articaine, suggesting
a neurotoxic effect15. Pogrel et al.16 indicated that 9
of their 12 cases of local anaesthetic administration
injuries involved the lingual nerve, two involved the
IAN and one was apparently confined to the chorda
tympani. They reported that just seven (58%) of their
patients experienced an electric shock sensation at the
time of injection, showing that the absence of this sign
should not preclude the diagnosis of a local anaesthetic
administration injury.
A relatively uncommon cause of IAN injury is
chemical or mechanical damage during root canal
treatment. Only one such patient was seen in the
present series, and surgical removal of extruded material within the mandibular canal was undertaken. In a
series of 61 patients with this problem reported by
Pogrel17, optimal recovery appeared to follow surgical
exploration and removal of any material within 48 h
of the initial treatment. This early intervention can
be extremely difficult to achieve for practical reasons
and is dependent upon immediate referral by the
endodontist to an appropriate specialist centre.
It is interesting that few of the many trigeminal
nerve injuries caused by facial bone fractures are
referred for assessment at a specialist nerve injury
clinic. The demographics of this population is very
different (often young males who have been
assaulted), but the nature of the nerve injury itself
may also differ; fractures are perhaps more likely to
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Characteristics of nerve injury patients

Robinson

lead to crush or minor traction injuries rather than the

partial or complete section injuries that can result
from iatrogenic damage. Recovery from a crush injury
is likely to be more successful, with less risk of the
development of dysaesthesia1.

Nerve damaged
In the Sheffield clinic, IAN injuries were commonest
(56% of patients), and 44% had a lingual nerve injury.
Again, this is similar to the pattern of referrals elsewhere, as at the Chapel Hill centre, 64% of patients
had an IAN injury and 29% had a lingual nerve injury5.
Conversely, in Hillerups Copenhagen study, 58% were
lingual nerve injuries and just 33% IAN injuries6, and
in Pogrel and Thambys4 study, 58% had lingual nerve
injuries and 52% IAN injuries, as some patients had
more than one nerve damaged.

Dysaesthesia
A substantial proportion of the referred patients
had the unpleasant painful sensations of dysaesthesia,
and this proportion was similar for both lingual nerve
(41%) and IAN (44%) injuries. In the Copenhagen
study, only 17% of patients were diagnosed as suffering from dysaesthesia6, and in the Chapel Hill study5,
a similar figure of 15% of the patients had neuropathic pain, but all of these had sustained an IAN
injury. In a study of 227 Swedish patients who had
been awarded compensation as a result of a trigeminal nerve injury, approximately 20% suffered from
periods of pain in the affected area18. The higher incidence of reported pain in the present study is difficult
to explain, but there may be cultural differences in
describing subjective experiences. Patients often have
difficulty in analysing their symptoms, sometimes
reporting them as unpleasant and uncomfortable,
but not painful. A comparably high incidence of
neuropathic pain (45%) was reported by Jskelinen
and colleagues19 when describing patients referred
for neurophysiological evaluation after a trigeminal
nerve injury. Surveys on the general population
suggest that patients with neuropathic pain are
more likely to be female and slightly older than the
average20, and this is another possible explanation for
the distribution of patients seen in the present study.

Treatment
When taking into account likely surgical outcomes, less
than half of the referred patients (41%) were considered appropriate for treatment. This is similar to the
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proportion in the study by Tay and Zuniga5, where 46%

were offered surgery, and it was undertaken in a third;
this suggests that similar criteria are being employed in
the two units. Of the 261 patients with lingual nerve
injuries described by Hillerup and Stoltze21, 86 (33%)
underwent surgical intervention, and this included
two patients where external neurolysis was the chosen
procedure. This latter procedure is usually only considered appropriate if a substantial proportion if the
nerve remains intact. In Pogrel and Thambys study4,
only 17% of their 163 patients were offered surgery,
and it was undertaken in just 9%; this might suggest
that their study initially included more patients with
minor injuries, and this might also explain the younger
mean age of their patients as described above.
The patients offered treatment in the present study
were most likely to be those with neuropathic pain.
Analysis of our outcomes previously has shown that
the proportion of patients with some pain may not
reduce9, but the level of the symptoms will often
decline10; this has also been reported in other studies22.

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2010 John Wiley & Sons A/S