J Oral Maxlllofac Surg

42 565-567. 1’384

Clinical and Anatomic Observations on

the Relationship of the Lingual /Verve to
the Mandibular Third Molar Region
JOHN E. KIESSELBACH, DDS,* AND JACK G. CHAMBERLAIN, f=t-iDt

The position of the lingual nerve in the mandibular third molar region was
measured and photographed in 34 cadaver dissections and 256 cases of
third molar extraction. In 17.6% of the dissections the lingual nerve was
found at the level of the alveolar crest or higher. Horizontally the nerve
contacted the lingual plate of the third molar in 62% of the specimens. Of
256 patients, the nerve was visualized above the height of the lingual plate
of the lower third molar in 12 (4.6%). These results document the vulner-
ability of the lingual nerve as it passes medially to the mandibular third
molar.

Injuries to the lingual nerve are possible during and scalpel. The vertical distance of the nerve
third molar extractions, ramus osteotomies. above or below the alveolar crest and the horizontal
alveoloplasties, and anesthetic injections.‘-3 In re- distance of the nerve from the lingual plate were
viewing the literature it was noted that detailed de- measured with calipers. At the same time the di-
scriptions and measurements of the exact location ameter and shape of the nerve were recorded.
of the lingual nerve relative to the third molar region
Clinical Ohser\wtion.s
of the mandible were lacking.4-6 The purpose of this
paper is to present quantitative data describing the In the course of 256 consecutive mandibular third
position and shape of the lingual nerve in the third molar extractions, attempts were made to carefully
molar area. expose and selectively photograph the lingual nerve
in its passage medial to the posterior body of the
Materials and Methods mandible in the third molar area. Extractions were
all performed by the buccal approach for surgical
Cadalver Dissections access. Most of the teeth were impacted.
Thirty-four adult cadaver heads were randomly Results
selected. Each head was sectioned sagittally, and
one side was used for dissection. The tongue was The results are presented in Table I and Figures
retracted medially, and a 4-5 cm lingual sulcular 1 and 2. All numerical data were analyzed by com-
incision was made. Using blunt and sharp dissec-
tion, the nerve was exposed from the posterior man- Table 1. The Shape and Distance of the
Lingual Nerve from the Bony Plate in the
dibular ramus area to the third molar region until
Lower Third Molar Region in 34
the point at which the nerve entered the tongue. Adult Cadaver Heads*
The mucosa and periosteum over the lingual plate
of bone were removed with a periosteal elevator Horizontal Distance
in mm from Vertical Distance in mm
Received from the Department of Anatomic Sciences. Uni- Lingual Plate from Alveolar Crest
versity of the Pacific School of Dentistry, San Francisco. Cali-
Mean
fornia.
* Formerly resident, Highland General Hospital. Oakland. 2 so 0.588 2 0.90 7 ‘79 below crest -t 1.96
-.-
California and University of the Pacific School of Dentistry: cur- Range 0.0-3.0 2.0 above crest-7.0 below crest
rently in private practice of oral and maxillofacial surgery.
t Professor and Chairman. * Of the 34 lingual nerves, ?I were round. seven were flat.
Address correspondence and reprint requests to Dr. Kiessel- and six were ovoid in shape. Shape was not significantly related
bath: 1204 Cottonwood Street. Woodland. CA 95695. to distances.

565
 566 LOCATION OF LINGUAL NERVE

FIGURE 1. Diagrammatic frontal section of the left third molar

region showing the mean horizontal and vertical distances of the
lingual nerve from the mandibular lingual plate and alveolar
crest.

puter and the significance of shape and distances

were calculated.

Cadaver Dissections
In the posterior mandibular area the lingual nerve
was located between the medial surface of the
ramus and medial pterygoid muscle. Although gen-
erally round in shape at this point, it was sometimes
ovoid or flat. The average diameter of the nerve was
1.86 mm. In the lower third molar region 61.7% of
the lingual nerves were round, 17.6% were oval,
and 20.5% were flat or ribbon-like. Three of the flat
nerves were only 0.5 mm thick. Shape was not cor-
related with specific distance from the bone.
The nerve emerged beyond the anterior edge of
the medial pterygoid and descended toward the
distal aspect of the third molar. It always passed
horizontally or anteroinferiorly medial to the third
molar. The submandibular duct usually, but not al-
ways, looped above the nerve as it dropped inferi-
orly and anteriorly into the sublingual space. The
parasympathetic fibers of the nerve branched off to
the submandibular ganglion before the nerve pene-
trated the anterior two thirds of the tongue.
The average horizontal distance of the nerve from
the lingual plate was 0.58 mm ? 0.9 (Fig. 1). In FIGURE 2 (top). Cadaver dissection of the lingual nerve
62% of the specimens, the nerve was in actual con- showing it touching the crown of the mesioangular soft tissue of
impacted tooth no. 32. The soft tissue covering the tooth has
tact with the bone. The average vertical distance of
been removed.
the nerve below the alveolar crest was 2.28 mm +
FIGURE 3 (cenrer, hortom). Clinical cases showing lingual
1.96. In 17.6% of the dissections the nerve was at
nerve (LN) lying above the alveolar crest in the third molar
the level of the alveolar crest or higher. In one case region (17s shows the extraction space of tooth no. 17).
the nerve passed through the retromolar pad 2.0
KIESSELBACH AND CHAMBERLAIN
mm above the lingual plate at the level of the oc-
clusal surface of an impacted third molar (Fig. 2).
Clinical Obsrrvatiom
Of the 256 extraction cases, twelve (4.5%)
showed the lingual nerve to be above the bony al-
veolar crest. (Fig. 3).
Discussion
Severance and repair of the lingual nerve still re-
main major problems in dentistry.7s8 Although the
nerve may be directly visualized after third molar
extraction, the classic anatomic descriptions have
not clearly described it as being juxtaposed to the
third molar alveolus.2.8q9 Hollingshead states that in
the third molar region the nerve “leaves the mas-
ticator space to pass downward lateral to the sty-
loglossus muscle . . . ,“‘O and Liebgott states that
the nerve “heads toward the lingual aspects of the
third molar alveolar area. . . .“I’ While these and
other authors have given descriptions of the lingual
nerve, they do not discuss the variability of its po-
sition. Our data quantitates the variability of the po-
sition of the lingual nerve in the third molar region.
The surgeon cannot rely on the lingual plate to act
as a protective barrier to the nerve during third
567
molar extraction, since the lingual nerve may lie
above the bone in this area. Moreover, three (8.8%)
of our dissections showed flat lingual nerves that
were 0.5 mm thick. As 25-gauge anesthetic needles
are also 0.5 mm thick, this may explain how an
anesthetic needle can seriously damage the lingual
nerve.
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