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Int. J. Oral Maxillofac. Surg.

2001; 30: 333–338


doi:10.1054/ijom.2001.0064, available online at http://www.idealibrary.com on

Research paper:
Dentoalveolar surgery

Anatomic position of the lingual F. W. Hölzle, K.-D. Wolff


Arzt für Mund-, Kiefer- und Gesichtschirurgie,
Plastische Operationen,
Knappschaftskrankenhaus, Klinikum der

nerve in the mandibular third Ruhr-Universitat, In der Schornau 23–25,


44892 Bochum

molar region with special


consideration of an atrophied
mandibular crest: an
anatomical study
F. W. Hölzle, K.-D. Wolff: Anatomic position of the lingual nerve in the mandibular
third molar region with special consideration of an atrophied mandibular crest: an
anatomical study. Int. J. Oral Maxillofac. Surg. 2001; 30: 333–338.  2001
International Association of Oral and Maxillofacial Surgeons

Abstract. The position of the lingual nerve in the mandibular third molar region
was measured and documented in 68 cadaver dissections (34 adult cadaver heads).
In 8.8% of the dissections, the lingual nerve was found at or above the level of the
alveolar crest. In the horizontal plane, the nerve contacted the lingual plate of the
third molar in 57.4% of the specimens. There was also a significant relationship
between the degree of mandibular crest atrophy and the distance from the nerve to
the molar region. The distance decreased with the degree of atrophy. There was no
Key words: third molar surgery; nerve injury;
significant difference between the two sides of the head. These results demonstrate lingual paresthesia; protection of the lingual
the vulnerability of the lingual nerve as it medially passes the mandibular third nerve; human anatomy.
molar and may help avoid lingual damage during surgery in the third molar and
retromolar region of the mandible. Accepted for publication 1 April 2001

The anatomic proximity of the lingual esthesia after surgical insertion of hypogeusia of one half of the tongue is
nerve to the mandibular third molar implants3. calculated to be 1:2 million after local
region plays an important role in plan- The risk of damaging the lingual nerve anaesthesia9. The incidence of a persist-
ning and performing surgical interven- during mandibular wisdom tooth sur- ent sensory deficit after osteotomy is
tions in this area. Nerve injury is gery differs in the literature. Horch reported to be 0.5–2% in English litera-
possible during removal of the third reports an injury incidence of 0.05%10 ture4,13,19. A-A gives an
molars, osteotomy of the mandibular and H 0.04%. About 250 000 11.5% incidence of reversible dysesthesia
branch, alveolar crest graft and by injec- wisdom teeth per year were removed in after mandibular wisdom tooth surgery2.
tion of local anaesthesia. Even excision the 1980’s in the old federal states of Thus, extensive knowledge about the
during tumour removal or the sequelae Germany. An incidence of 0.05% means position of nerves in the mandibular
of trauma may injure the nerve1,20,23. 125 nerve lesions per year. The prob- third molar region is indispensable for
There are also reports of lingual par- ability of irreversible numbness and surgery in this area.
0901-5027/01/040333+06 $35.00/0  2001 International Association of Oral and Maxillofacial Surgeons
334 Hölzle et al.

A survey of the literature revealed that


virtually no detailed descriptions or
measurements of the lingual nerve in the N. alveolaris inf.
lower third molar region have been
reported for many years21. In 1984,
K & C were the
N. mylohyoideus
first to perform an exact quantitative
evaluation on cadaverous specimens and B' A'
to attempt atraumatic in vivo exposure A
Distal
B incision
of the nerve in 256 wisdom tooth remov-
als to study its course medial to the C
N. lingualis
posterior alveolar crest in the retro- D
molar region12. In 1995, P et al. X
measured in three dimensions the exact
anatomic position of the lingual nerve
for the wisdom tooth region. For this,
they used a reproducible osseous point, FK
taking the dentulous jaw into account17.
There have not yet been any studies K2
considering alveolar crest atrophy in Foramen mentale
addition to determining a reproducible K1
osseous point as a fixed point for meas- Fig. 1. 3D-Illustration of the measured points and distances.
uring and evaluating dental status.
Thus, the aim of this study was to
examine whether the lingual nerve has a incision was marginally and mesially + The distance of the lingual nerve to
relatively higher or closer position to the lengthened in the lingual region. Starting point A in the vertical plane (defined
alveolar crest due to mandibular atrophy distally, the lingual mucosa and the peri- as point C or segment AC).
and is therefore exposed to a higher osteum were removed with a bone rasp + The medial bending point of the nerve
risk in surgery near the bone. Such an in the mesial direction. The lingual nerve towards the tongue was defined as
additional risk is possible especially in was demonstrated by blunt dissection Point D and the distance to point B
osteotomies or during implantation. but not exposed to prevent changing its determined (segment BD).
Moreover, the aim was to measure the anatomic relationship to the adjacent + The distance of the most cranial point
position of the nerve in the mandibular structures. of the lingual nerve in its mandibular
third molar region in all three dimen- The anterior measuring points and course was measured to the upper
sions and to examine it for bone contact. distances were recorded with a precision edge of the mandibular crest.
Another objective was to determine the vernier gage and those more distal and + The point of ramification was deter-
distance of the lingual nerve to the typi- difficult to reach were calipered with a
cal incision in surgical wisdom tooth mined and defined as point X.
measuring compass. Stepwise dissection + A B was defined as the shortest dis-
removal. was performed in such a way as to
According to N & H, tance of the lingual nerve to the clas-
reliably obtain measurements without sical incision in the surgical removal
the lingual nerve either has a mono- or falsifying them by too great a change in
oligofascicular structure in the pterygo- of wisdom teeth. The soft tissue point
the anatomic site. Distances to the A was dependent on the nerve pos-
mandibular space15. The nerve begins to nerves were measured from the bound-
branch off medial to the posterior ition and was located on the incision
ary of the nerve inclining towards the
molars and has a polyfascicular struc- line of the distal relief.
other measuring point.
ture there. The point of ramification is + The shape of the nerve was character-
Since the oblique line of the ramus
also examined in the present study and ized as round, oval or flat and its
mandibulae in the atrophied mandibular
placed in relation to a distal fixed point, diameter was determined at point
crest is frequently very indistinct, it can-
the mental foramen and the tooth region C.
not be used as an orientation or marking
in dentulous patients. + The height of the mandibular crest
aid. Thus, the reproducible transition site
It was also necessary to check the of the horizontal to the vertical branch of was measured at the level of the
assertion by R & M that ana- the ramus mandibulae is more or less foramen mentale (K1) as well as at its
tomic lingual nerve variations are of fixed as a retromolar pad and defined as lowest point (K2). Moreover, the dis-
secondary importance18. osseous measuring point A. Starting at tance between the upper osseous edge
this point, the following measurements of the foramen mentale and that of
were performed, which are demonstrated the mandibular crest (FK) was deter-
Material and methods
by the illustration in Fig. 1: mined. The ratio FK to K1 was a
Thirty-four formalin-fixed heads were good, objectifiable indicator of the
divided sagittally. The 68 dissections + The horizontal distance of the lingual degree of atrophy.
were prepared as follows: In dentulous nerve to the lingual mandibular crest + All measurements and the unilateral
mandibles or in those with second surface at the level of point A. position of the nerve were compared
molars, a 1 cm long distal relieving inci- + The shortest distance of the lingual to the opposite side and statistically
sion was made in the direction of nerve to point A in the sagittal plane analyzed taking the tooth status into
the ascending mandibular branch. This (defined as point B or segment AB). consideration.
Anatomic position of the lingual nerve in the mandibular third molar region 335

lingual buccal The mean nerve diameter at point C


was 2.74 mm (range: 1.9 mm to 3.6 mm;
7.83 mm standard deviation: 0.3 mm). Fifty per-
cent of the nerves were oval, 32.3%
N. lingualis round and 17.7% rather flat. The shape
mandibular crest of the nerves did not correlate to the
distance from the mandibular bone.
0.86 mm Osseous mandibular crest height at
the level of the foramen mentale (K1)
Fig. 2. The frontal incision through the left third molar region shows the mean horizontal and
was a mean 22.89 mm. Values ranged
vertical distance of the lingual nerve to the lingual surface and the mandibular crest at the level
of the defined measurement point A. from 11.8–32 mm with a standard devia-
tion of 4.44 mm. The lowest height of
the mandibular crest (K2) was always
Results vulnerable nerve position significantly farther distal and a mean of 2.7 mm
correlated to the degree of mandibular less than at the height of the foramen
After statistically analyzing 1088 crest atrophy (right: P=0.003; left: mentale. The distance from the upper
measurements, the following results were P=0.001). In this connection, one corpse edge of the foramen mentale to that of
obtained. The mean age of the prepared had a high atrophy in the area of the the mandibular crest (FK) was a mean
cadavers was 78.82 years and the median lower first molar, with no teeth present of 8.97 mm with a maximum of
80 years. Standard deviation was 7.63 here, and there the nerve was only at the 15.5 mm. On one side, the foramen men-
years; the youngest was 52 and the oldest level of the mandibular crest or even tale directly contacted the mandibular
94 years. There were 19 female and 15 1 mm above it on one side. Mandibular crest, which only had a total height of
male corpses. Forty four mandible dis- crest atrophy could be measured and 14 mm. The foramen-mandibular crest
sections were edentulous; 10 had less and thus objectified as a quotient of the distance was entered as 0 mm in the
14 more than 4 teeth. distance between the foramen mentale calculations. The degree of mandibular
The degree of mandibular crest atro- and the upper edge of the mandibular crest atrophy was determined as a ratio
phy was high in 10 cadavers, moderate crest to the total height of the mandibu- of FK to K1. The ratio of the foramen-
in 15 and slight in nine. The mean hori- lar crest (FK/K1) at this site. upper mandibular crest edge distance to
zontal distance of the lingual nerve to The shortest distance of the lingual the entire mandibular crest height at this
the lingual mandibular crest surface at nerve to the distal relieving incision was site was a mean 39.19%.
the level of point A was 0.86 mm with a a mean 4.41 mm with a standard devia- Dentulousness affects the nerve pos-
standard deviation of 1.00 mm. In 57.4% tion of 1.44 mm. The maximal distance ition as follows: the nerve was closer to
of the cases, the nerve had direct contact was 9 mm, and in one head specimen the point A in edentulous jaws and its mesial
with the bone. The greatest distance was nerve was dissected by the distal reliev- distance from that point to the upper
4 mm. ing incision. The ramification site (X) mandibular crest edge was markedly
The mean vertical distance of the was a mean mesial distance of 20.62 mm shorter in partially dentulous and
nerve to point A was 7.83 mm with a from point C. This point was 57.13% of edentulous jaws.
mean deviation of 1.65 mm. The dis- the distance between C and the foramen Comparison of the means with one-
tances ranged from 4.5 mm to 14 mm. mentale. sided variance analysis followed by the
Figure 2 shows both the horizontal and
vertical distance of the nerve to point A.
The mean distance from point B to
point A in the sagittal plane was
5.97 mm with a standard deviation of
1.29 mm. The measurements ranged
from 2.5 mm to 10.5 mm. When the
nerve was closest to point A, point B was
always distal to A. The mean sagittal
distance of the nerve from point B up
to its medial bend toward the tongue
(segment BD) was 21.47 mm.
The shortest distance of the nerve over
its entire course from point A in the
mesial direction into the paralingual
space towards the upper edge of the
mandibular crest was a mean 5.91 mm
with a standard deviation of 2.3 mm and
considerable scattering of the values.
The maximal distance with a very deeply
coursing nerve was 12 mm. The nerve
was at or above the alveolar crest level in
four heads, two bilaterally, and thus in a Fig. 3. Superficial and exposed right lingual nerve position in the mandibular crest with
total of 8.82% of the cases (Fig. 3). This pronounced atrophy and a fraction of the foramen-mandibular crest distance to the entire
very high and, therefore, exposed and mandibular crest height <20%. l: N. lingualis, m: N. mentalis, F: Foramen mentale, t: tongue.
336 Hölzle et al.

unilateral stayed deep in the floor of the


mouth and did not cross the lingual
nerve.
One cadaver unilaterally had an
extremely thin lingual nerve with a diam-
eter of 1.9 mm. In another corpse, the
lingual nerve showed very high uni-
lateral ramification and was double-
stranded at the level of point C. Two
cadavers each had an extremely deep
lingual nerve on one side at 12 mm from
the mandibular crest.
In one corpse, the hypoglossal nerve
was directly adjacent to the lingual nerve
and submandibular duct. A pronounced
paramandibular lipoma was seen in one
head dissection.

Discussion
Fig. 4. Double foramen mentale with two mental fascicles exiting from each. m: N. mentalis, F: After the lingual nerve passes through
Foramen mentale, c: top view of mandibular crest. the deep lateral facial region, it enters
the floor of the mouth between the man-
dibular branch and the medial pterygoid
muscle. Behind the dorsal edge of the
mylohyoid muscle, the sublingual space
is broadly connected to the submandibu-
lar space24. Like the styloglossus muscle,
the nerve is also at the aboral end of
the sublingual oral sinus at the level
of the lower third molar just beneath the
mucosa and is only separated by this and
some connective tissue7. Nerve injuries
in this region can predominately be
attributed to dental interventions and
the close spatial relationship of the nerve
to the wisdom tooth region24.
Numerous authors describe the nerve
but discuss the variability of its position
to a much lesser degree. Our measure-
ments quantify the position of the nerve
and provide information about its
incidence and range.
In the present study, the mean
Fig. 5. Nerve anastomosis between the mylohyoid and lingual nerves. l: N. lingualis, y: N. distance of the lingual nerve to the
mylohyoideus, a: nerve anastomosis, t: tongue, c: mandibular crest. lingual mandibular crest surface is
0.86 mm1 mm at the level of point A.
Scheffe test showed that the more dentu- Two corpses had a unilateral nerve The nerve directly contacted the bone in
lous the jaw, the less marked the man- anastomosis (as demonstrated in Fig. 5) 57.4% and the greatest distance was
dibular crest atrophy (right: P=0.02; left between the sensory lingual nerve and 4 mm. K & C,
P=0.06). the motor mylohyoid nerve from the who also examined 34 heads, reported a
inferior alveolar nerve. This corresponds distance of 0.59 mm0.9 mm. There
Pre-existing variations
to an incidence of just under 3%. was bone contact in 62% of the cases12.
In these cases, there was a pronounced In 20 head specimens, P et al.
One corpse had a double foramen men- anastomosis with a diameter of over found a horizontal distance of
tale on one side. There were two mental 1 mm. In one case, the anastomotic 3.45 mm1.48 mm. The values ranged
nerve fascicles exiting from each of the branch to the lingual nerve was larger from 1.0 mm to 7.0 mm17. Using MRI,
foramina. than the distal mylohyoid component. M et al. examined the position of
A bilateral double foramen mentale The submandibular duct (of Wharton) the lingual nerve in 10 volunteers aged
was seen in one head specimen. On the primarily crosses over the lingual nerve 21–35 years. All subjects had rudimen-
right side, two nerves each originated in the premolar region. In one corpse, tary lower wisdom teeth and no maxillo-
from the foramina and, on the left, two the unilateral duct was tied off by facial surgery in their history. The
from the cranial and one from the a network of lingual branches. In a horizontal distance here to the lingual
caudally located foramen (Fig. 4). total of four corpses, Wharton’s duct aspect of the mandible in the wisdom
Anatomic position of the lingual nerve in the mandibular third molar region 337

tooth region was 2.53 mm0.67 mm. In nerve damage8. Our incision directly up Peripheral polyfascicular reconstruction
five of the 20 cases (25%), the nerve to the ascending branch is certainly the of the lingual nerve can be done in
directly contacted the bone. The mean most medial that should be selected. In individual cases and its fasciculus con-
vertical distance of the nerve to upper the surgical removal of wisdom teeth, it nected to that of the sural nerve with a
mandibular crest edge was 2.75 mm facilitates distolingual exposure of the perineural suture8.
0.97 mm with range of 1.52–4.61 mm14. mucoperiosteum flap and subsequent The correlation between the position
In our study, the vertical distance was mobilization of the tooth, but carries the of the lingual nerve to the upper man-
7.83 mm with a standard deviation of risk of a lingual lesion. In view of the dibular crest edge and mandibular crest
1.65 mm and a range of 4.5–14 mm. results, a more buccal relieving incision atrophy has hitherto not been the subject
P et al. found a vertical distance is safer and is therefore recommended. of extensive studies. Although this con-
of 8.32 mm (standard deviation: There is a clear discrepancy in the mean nection seems obvious, it is not necessar-
4.05 mm)17. K & C- nerve diameters given in the literature. ily the case. This study shows that the
 measured only 2.28 mm1.96 mm, M et al. reported the lingual nerve extent of atrophy is related to age but
although the values extended from 2 mm diameter to be 2.54 mm with a range of even more to edentulousness. However,
over to 7 mm below the crest12. All four 1.58–3.13 mm. The shape of the nerve since there is often a loss of muscle tone
studies mentioned deal with the distance was round in 45% of the cases, oval in and connective tissue tension with
of the nerve from the mandibular crest in 30% and flat in 25%14. K & advanced age, the nerve may also
its further mesial course in the paralin- C found a mean nerve diam- descend into the floor of the mouth and
gual space. In our study, the mean dis- eter of 1.86 mm. The nerves were round thus not change its relative position to
tance was 5.91 mm with a standard in 61.7% of the cases, oval in 17.6% and the mandibular crest. Further studies are
deviation of 2.3 mm. There was a con- flat in 20.5%. Three of the flat nerves necessary to confirm this connection.
siderable range of values with a maximal were only 0.5 mm thick. The shape did
The ratio of the foramen-upper man-
distance of 12 mm, and, in a total of six not correlate to the distance from the
dibular crest edge to the entire mandibu-
head dissections, the nerve was found at jaw bone12.
lar crest height at this position is a very
or above the alveolar crest. The authors P et al. reported a mean nerve
suitable measure of mandibular crest
largely agree on this finding. The per- diameter of 3.45 mm. The standard
atrophy and agrees with the ‘prima
centage of nerves found at or above the deviation was 1.00 mm with a range of
vista’ estimation of atrophy into ‘high’,
mandibular crest and thus particularly 2.5–4.5 mm17. The mean nerve diameter
endangered by this exposed position is in P et al. is 80% above that ‘moderate’ and ‘slight’.
8.82% in our study, 10% in M et al. reported by K & C- At this point it should be considered,
using MRI, 15% in P et al. and . Moreover, lowest value found by whether this method would also be
17.6% in K & C- P et al. did not even reach the suited for radiological classification
12,14,17. The latter even reported one mean value of K & C- based on pantomograms. One only has
nerve that passed through the retro- . In our study the mean diameter to measure two lengths on the X-ray and
molar region 2 mm above the lingual was 2.74 mm with a standard deviation divide them. Manufacturers of X-ray
crest border at the level of the occlusal of 0.3 mm. Values ranged from 1.9– devices use different magnification fac-
surface of an impacted wisdom tooth 3.6 mm. The nerves were oval in 50.0% tors. However, since both values are
and would, thus, have certainly been of the cases, round in 32.3% and flat in placed in relationship to each other with
dissected by a classical incision12. 17.7%. The shape of the nerve did not the same magnification, the ratio
The mean distance of point B from correlate to the distance from the remains constant and can thus be com-
point A in the sagittal plane was alveolar bone. Changes of shape of pared to the diverse magnifications of
5.97 mm with a standard deviation of nerves may be due to post-mortem arte- other pantomograms. In addition, the
1.29 mm. P et al. found a mean facts and/or formalin fixation. To this foramen mentale is almost always clearly
distance of 4.45 mm with a standard issue we neither found publications nor visible and usually located between the
deviation of 1.48 mm17. At the shortest experienced anatomists or pathologists. mandible premolars in dentulous jaws,
distance from the nerve to point A, point To answer this question we looked at the so that the teeth do not interfere with the
B was distal to point A in both studies. shape of the lingual nerve in 15 fresh determination of the entire mandibular
The mean sagittal course of the nerve cadavers without fixative added. In this crest height. This would provide a simple
from point B to its medial bend to- 30 nerves measured it was oval in 46.7%, method for classifying mandibular atro-
wards the tongue (segment BD) was round in 33.3% and flat in 20.0%. We phy and promote understanding among
27.7 mm5.69 mm in P et al. and therefore conclude the influence of post- dentists.
27.47 mm3.3 mm in our study17. mortem formalin fixation on the shape A total of three double mental
The shortest distance of the lingual of the nerve as minimal. foramina, each with a nerve exit, were
nerve to the distal relieving incision was The nerve started to ramify a mean of determined in 68 prepared mandibular
a mean 4.41 mm. In one head dissection, 20.62 mm mesially from point C. This dissections. In two mandibular dissec-
the nerve was bisected by the distal site was 57.13% of the distance between tions, atrophy was so severe that the
relieving incision. K & C and the foramen mentale. In dentu- mental nerve exited at the mandibular
C reported a situation with lous jaws, ramification was primarily crest.
similar superficial nerve course12. located in the distal premolar region and It is exactly during abscess incision
H, who studied lingual is thus somewhat mesial to the position that the mental nerve is easily dissected,
nerve damage in Schleswig-Holstein, the reported by N & H15. since there is no visualization as in other
northern part of Germany, from 1981 to This site is clinically relevant if, for operations like apicectomy11. A pre-
1986, determined that an incision too far example, a sural nerve graft is required operative X-ray should therefore always
in the lingual direction promotes lingual for reconstruction of a nerve lesion. be performed.
338 Hölzle et al.

In two corpses, there was a pro- in the mesial paralingual region, if there mandibular third molar region. J Oral
nounced nerve anastomosis on one side is marked mandibular crest atrophy. Maxillofac Surg 1984: 42: 565–567.
between the sensory lingual nerve and This is not only true for oral surgical 13. M D. Lingual nerve damage follow-
the motor mylohyoid nerve from the procedures like osteotomies and ing lower third molar surgery. Int J Oral
inferior alveolar nerve, in one case with a excisions but also for the insertion of Maxillofac Surg 1988: 17: 290–294.
14. M M, H LE, S HW,
diameter of more than 1 mm. L & intraosseous implants.
C DW. Assessment of the lingual
W also report a fiber change nerve in the third molar region using
between these two nerves16,24. magnetic resonance imaging. J Oral
Acknowledgments. The authors would
B described very fine anatomical Maxillofac Surg 1997: 55: 134–137.
like to express their many thanks to
branches between the lingual and mylo- 15. N FW, H JE. Anato-
Professor Graf, M.D., from the Institute
hyoid nerves5. S even refers mische Untersuchungen zur faszikulären
of Anatomy of the Free University,
to ‘Bichat’s nerve’22. F also found Struktur einzelner Hirnnerven als Grund-
Berlin for providing the study specimens
a connecting branch between these two lage zur Vermeidung von Mißerfolgen
as well as her kind support during the
nerves6. R & M18, who studied bei der Mikrochirurgischen Nervnaht.
entire study. Fortschr Kiefer Gesichtschir 1985: 30:
the course of the lingual nerve in 48 head
dissections, reported this connection in 51–54.
eight cases, thus in a third of their study References 16. P-T. Les NERFS en schemas.
specimens. They are of the opinion that Anatomie et Physiolpathologie. Paris
1. A CC. Dysesthesia of the lingual 1925: 118.
the mylohyoid nerve is a mixed nerve, and inferior alveolar nerves following 17. P MA, R A, S B,
which gives off postganglionic vegetative third molar surgery. J Oral Maxillofac A A. The relationship of the lingual
fibres from the anastomotic branch to Surg 1986: 44: 454–457. nerve to the mandibular third molar
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the value reported by R & M18. 19. R JP. Permanent damage to inferior
W H, N I. Lingual paresthe- alveolar and lingual nerves during the
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examinations in patients. There was no 4. B CW, B PA. Lingual 108–110.
correlation between measurements made nerve damage associated with removal of 20. S LJ. Lingual anesthesia follow-
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this underlines the vulnerable position of 103–107. 1973: 31: 918.
this nerve during intraoral or maxillo- 5. B X. Traite d’ A v natomie descrip- 21. S GC. Lingual exposure during
facial surgery14. K & tive. Brossen Paris 1802, Nouvelle edi- mandibular third molar surgery. Int J
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6. F E. Zwei Sonderfälle des N. lingua- 22. S J. A propos du nerf de
surgeon cannot depend on the lingual lis. Anat. Anz., Jena 1956: 103: 187–191.
osseous lamella as a protective barrier Zlobikowski. Fol morph Warzawa 1933:
7. G H. Anatomy descriptive and 4: 164–170.
during wisdom tooth removal, since the applied. London New York Toronto 23. V G AV, T B JJ, B
nerve may lie over the bone in the soft 1932: 994. G. Clinical consequences of complaints
tissue12. The incision, especially the dis- 8. H B. Verletzung des Nervus and complications after removal of the
tal relieving incision for wisdom tooth lingualis—Eine klinische und tierexperi- mandibular third molar. Int J Oral Surg
osteotomy, should not be made medial mentelle Studie. Habilitationsschriften 1977: 6: 29.
to the ascending branch because the der Zahn-, Mund- und Kieferheilkunde, 24. V L T, W W. Praktische
Quintessenz Verlags-GmbH, Berlin 1989:
variability of the nerve and its possible Anatomie Bd.1, Teil 2: Hals. Berlin
21–22. Göttingen Heidelberg: Springer Verlag
surface positions may cause a lesion. The 9. H B. Verletzung des Nervus
tangent to the distal surface of the third 1955: 114–115.
lingualis—Eine klinische und tierexperi-
molar is also suited as a guideline for mentelle Studie. Habilitationsschriften
orientation. The incision should be made der Zahn-, Mund- und Kieferheilkunde, Address:
at a 45 angle to this tangent in the Quintessenz Verlags-GmbH, Berlin 1989: Dr. med. Dr. med. dent.
buccal direction. Moreover, during free 81–82. Frank Hölzle
fraising of the lower wisdom tooth, 10. H HH. Iatrogene Nervläsionen bei Klinik für Mund-, Kiefer- und Plastische
attention should be paid to the fact that der zahnärztlichen Behandlung. Gesichtschirurgie
a raspatory should be pushed disto- Zahnärztl Mitt 1984: 7: 708–715. Knappschaftskrankenhaus
11. H HH. Zahnärztliche Chirurgie. Klinikum der Ruhr-Universität Bochum
lingually between the periosteum and
Praxis der Zahnheilkunde 9. 3. Auflage, In der Schornau 23–25
bone in order to protect the periosteum Urban & Schwarzenberg, München Wien 44892 Bochum
and lingual nerve9. Baltimore 1995: 51–52. Germany
Furthermore, a relatively high 12. K JE, C JG. Clini- Tel.: +49 (0) 234-299 3500
position of the nerves must be taken into cal and anatomic observations on the Fax: +49 (0) 234-299 3509
account for surgical interventions even relationship of the lingual nerve to the E-mail: frank.hoelzle@ruhr-uni-bochum.de