Dr. Bhavik Miyani, Resident Doctor at Department of Oral & Maxillofacial Surgery, Narsinhbhai Patel Dental College & Hospital, Visnagar.

1. GOOD MORNING…
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2. #4TH JOURNAL CLUB PRESENTATION
Presented by,
Dr. Bhavik Miyani
2nd Year PG, Dept. of OMFS.
Guided by,
Dr. Anil Managutti
Dr. Shailesh Menat
Dr. Rushit Patel
Dr. Jigar Patel

3. TITLE OF ARTICLE
Sensory nerve impairment following mandibular third molar
surgery
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4. CRITICS OF TITLE
• Title is appropriate.
• Type of study is not mentioned in title.
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5. CONTENTS
1. About the Journal
2. About the Author
3. Abstract
4. Introduction
5. Patients and Methods
6. Results
7. Discussion
8. Review of Literature
9. References
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6. • Journal of Oral & Maxillofacial Surgery
• Peer reviewed journal
• Open access PubMed Indexed Journal 11021704
• Impact factor- 1.333(2012)
• Published By- Elsevier Inc.
• Volume 59
• Issue 10
• Year of Publication- October 2001
• Page No.- 1012 to 1017
ABOUT THE JOURNAL
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7. 1. Anwar B. Bataineh, BDS, MScD, CSOS (Sarajevo), MDSc (Leeds)
*Associate Professor of Oral and Maxillofacial Surgery,
- Department of Oral Medicine and Oral Surgery,
- Jordan University of Science & Technology, Faculty of Dentistry, Irbid-
Jordan.
ABOUT THE AUTHOR
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8. ABSTRACT
• Purpose: This prospective study reports the rate and factors influencing sensory
impairment of the inferior alveolar and lingual nerves after the removal of impacted
mandibular third molars under local anesthesia.
• Patients and Methods: There were 741 patients with 741 mandibular third molars
removed under local anesthesia during a 3-year period from 1994 to 1997.
Standardized data collection included the patient’s name, age and gender, side of
operation, angulation of the tooth, lingual flap elevation, use of vertical or horizontal
tooth division, the experience of the operator, and the occurrence of lingual and/or
inferior alveolar nerve paresthesia.
• Results: Postoperative lingual nerve paresthesia occurred in 19 patients (2.6%). There
was a highly significant increase in the incidence associated with raising of a lingual
flap (P< .001). The incidence of inferior alveolar nerve paresthesia was (3.9%). It was
highest in the under 20-year-old age group (9.8%), and there was a highly significant
relationship to the experience of the operator (P< .001). Statistical analyses revealed
that both lingual and inferior alveolar nerve paresthesia were unrelated to the other
variables.
• Conclusions: The elevation of lingual flaps and the experience of the operator are
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9. CRITICS OF ABSTRACT
• Type of study and aim of study is mentioned in
abstract.
• Abstract is well structured.
• Keywords are not mentioned in abstract.
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10. INTRODUCTION
• The removal of impacted mandibular third molars is one of the most frequently
performed oral surgical procedures, and it can be complicated by postoperative
disturbances caused by nerve damage.
• In previous studies, the incidence of damage to the lingual nerve during lower
third molar surgery has been reported to vary from 0% to 23% and that to the
inferior alveolar nerve from 0.4% to 8.4%.
• Many factors have been suggested as predisposing to these complications.
Thus, lingual nerve injury has been related to such iatrogenic causes as poor
flap design, clumsy instrumentation, and fracture of the lingual plate. 10

11. • More recent evidence appears to indicate that the most strongly
implicated factor for lingual nerve injuries is the raising and
retracting of a lingual mucoperiosteal flap and the insertion of a
Howarth periosteal elevator, particularly when done under general
anesthesia.
• Injury to the inferior alveolar nerve has been related to more
deeply impacted teeth, to less-experienced surgeons, to the use of
burs to remove bone, and to the relationship of tooth roots to the
mandibular canal.
• This prospective study reports the rate and factors influencing
sensory impairment of the inferior alveolar and lingual nerves after
the removal of impacted mandibular third molars under local
anesthesia.
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12. CRITICS OF INTRODUCTION
• It describes aim of the study.
• Type of study is mentioned in the
introduction.
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13. PATIENTS AND METHODS
• The patients included in this prospective study were those referred to
the Oral and Maxillofacial Surgery Unit, Faculty of Dentistry, Jordan
University of Science and Technology for surgical removal of
symptomatic impacted mandibular third molars during a 3-years
period from 1994 to 1997.
• Teeth associated with pathologic lesions such as cysts were excluded.
• The operators performing the extractions ranged from those with many
years of surgical experience to those who had recently started their
training. One surgeon (A.B.B.) confirmed the findings in every case. 13

14. • A total of 741 mandibular third molars in 741 patients were
removed under local anesthesia.
• All teeth were removed from a buccal approach, generally using
a crestal incision extending to the distal of the second molar,
followed by second incision extending downward and forward to
the buccal sulcus.
• A variation in the later incision, extending to the first molar, was
sometimes used depending on the angulation of the tooth.
• When it was necessary to raise a lingual flap and remove distal
bone, a Howarth periosteal elevator was placed carefully over the
bone on the lingual side until it dropped into a tissue plane
between the lingual periosteum and the lingual plate of bone. 14

15. • This was done to displace the tissues on the lingual side, to improve
visibility, and to afford some protection for the lingual nerve during
bone removal, tooth division, and elevation.
• Bone removal was done with burs in the conventional manner and, if
necessary, the tooth was divided with burs before elevation.
• A standardized data form was completed in which the name, age, and
sex of the patient, side of operation, angulation of the tooth, lingual
flap elevation, use of vertical or horizontal tooth division, experience of
the operator, and the occurrence of lingual and/or inferior alveolar
nerve paresthesia or anesthesia were recorded.
• All the patients were reviewed on the first postoperative day and again
1 week after surgery.
• Patients with altered lingual and/or labial sensation were followed
weekly for 3 months. 15

16. • Direct questioning of the patient concerning any tingling or numbness
of the tongue or lip was used to determine impairment at each
examination period.
• The presence or absence of sensory alteration was confirmed by the
response to probing using a sharp dental probe and the opposite blunt
end in a random manner.
• The sensation elicited by pricking the tongue, the mucosa, the lip, and
the skin depended to a considerable extent on the strength of the
stimulus and varied from light touch to pressure or pain.
• The data obtained were statistically analyzed using the chi-square test
(X2) to investigate whether the incidence of anesthesia or paresthesia
varied according to each factor independently.
• The probability (P) was also calculated using the chi-square test.
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17. CRITICS OF PATIENT AND METHOD
• Sample size is sufficient.
• Inclusion and exclusion criteria are not mentioned.
• Method of disimpaction is mentioned in detail.
• Statistical analysis test is mentioned.
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18. RESULTS
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19. 19

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21. • There were 417 males and 324 females in the study group. Four hundred
sixty-seven of the 741 patients were between 20 and 30 years old, and 213
were older than 30 years of age; Table 3 shows the age groups of the
patients.
• Details of the third molar angulation are given in Table 4. Of the total
operations, 72.8% were performed by experienced operators and 27.2% by
inexperienced operators (Table 5).
• A lingual soft tissue flap was raised in only 29% of cases (Table 6). Forty-one
percent of the teeth were extracted without bone removal; burs being used to
remove the bone in the remaining 59% (Table 7).
• Teeth were removed without tooth division in 35.5% of cases (Table 8).
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22. • Postoperative lingual paresthesia occurred in 19 patients (2.6%). Statistical
analysis revealed that the paresthesia was unrelated to age, sex, side of
operation, angulation of the tooth, status of the operator, removal of bone, or
tooth division.
• However, there was a highly significant increase in the incidence associated with
raising of a lingual flap (P< .001).
• The incidence of inferior alveolar paresthesia was highest in the under 20-year-
old age group (9.8%), and there was a highly significant relationship to the
experience of the operator (P< .001).
• Sensory impairment was transient in all cases and resolved over varying periods
from 1 week to 3 months (Table 9).
• All patients had only paresthesia; none had anesthesia. 22

23. CRITICS OF RESULT
• Results in text match with the table.
• Testing Methodology is also mentioned.
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24. DISCUSSION
• Injury to either the lingual or inferior alveolar nerves during the removal of
mandibular third molars is a distressing complication for the patient, who
should be informed of the potential surgical risks before the operation.
• This warning also should be recorded clearly in the clinical notes.
• It has been suggested that the problems arising from lingual nerve
involvement and those related to inferior alveolar nerve damage and
sensory loss have been both under-reported and minimized.
• MacGregor noted that long-term studies are lacking and stated that such
information would be important for both scientific and medicolegal
purposes.
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25. • Despite every effort to avoid trauma to the lingual nerve during third molar
extraction, lingual nerve anesthesia, paresthesia, or dysesthesia can result.
• Close proximity of the lingual nerve to the alveolar bone is not unusual, and
its possible location near the alveolar crest renders the nerve highly
vulnerable to trauma during third molar extraction.
• Variations in the path of the lingual nerve actually exist in a significant
percentage of the population; a fact of particular importance for the
surgeon, and a likely explanation for the problems experienced with the
lingual approach.
• Kiesselbach and Chamberlain and Miloro et al found the lingual nerve to be
above the bony alveolar crest in some cases. Such variations may predispose
to lingual nerve injury.
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26. • Carmichael and McGowan found that dysesthesia of the inferior alveolar
nerve occurred more often if the tooth was horizontally impacted and less
often in those that were vertically impacted.
• Kipp et al stated that horizontally impacted mandibular third molars were
statistically related to postoperative sensory changes and also agreed with
Wofford and Miller that the use of burs and the removal of bone were
significantly related to the incidence of postoperative paresthesia.
• None of these statements was supported by the findings in the present
study. In fact, the only statistically significant factor in relation to inferior
alveolar nerve paresthesia in this series was the experience of the operator.
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27. CRITICS OF DISCUSSION
• The points mentioned in material & method and
results are justified by discussion.
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28. REVIEW OF LITERATURE
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29. 29

30. REFERENCES
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32. • 23. Rood JP: Permanent damage to inferior alveolar and lingual nerves during the removal of
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33. • 32. Bruce RA, Frederickson GC, Small GS: Age of patients and morbidity associated with mandibular
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34. CRITICS OF REFERENCES
• References are well quoted in article.
• Author followed Vancouver method for
quoting references.
• Author has referred enough references for
his study.
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