The document discusses nerve injuries, specifically injuries to the inferior alveolar nerve (IAN). It covers the classification, etiology, signs, symptoms, and treatment/management of IAN injuries. Several key points: - IAN injuries are most commonly caused by third molar surgery or endodontic treatment and can result in sensory disturbances like numbness, tingling, or pain in the lower lip and chin. - Injuries are classified based on the severity of nerve damage, ranging from neurapraxia (mild impairment) to neurotmesis (complete nerve severance). - Radiographic exams like OPGs and CT scans can help identify anatomical features that increase risk of I

1. JAMES

2. Introduction
Classification
Etiology
Treatment / Management
Conclusion

3.  Nerve injuriescan be painful and affect the patient’s quality oflife.
 the most common cause of IAN injuryis third molar surgery, owing to the close anatomical relationshipbetween the third
molar root complex and the mandibular canal
 Permanent injury to the IAN in third molar surgery ranges between 0.4% and 23%
 The removal of mandibularthird molars, especially whensurgical exposure is necessary, is followed by postoperative
complaintssuch as pain, trismus, swelling and pain on swallowing. Sometimes the patient feels ill and shows an elevated
body temperature,dry sockets (0.5 % to 30 %)
The patients’overall subjectiveimpression of nerve functionand the tactile and thermal stimuli
were ratedas follows:
Score 0: No perception of stimulus
Score 1: Perception of touch or temperature without ability to discriminate the quality of the
stimulus
Score 2: Perception of the quality of stimulus less clear than on the healthy side
Score 3: Normal sensory perception of tactile and thermal stimuli.

4.  Severe injury to the inferior alveolarnerve (IAN) following endodontic treatmentin the posteriormandibularteeth is a rare but
serious complicationresulting in disabling sensorydisturbances such as pain, hypoesthesia, paresthesia, and dysesthesiaof the
lower lip and chin are
 According to the IASP (InternationalAssociation for the Study of Pain), paresthesia hasbeen defined as ‘‘an abnormal
sensation,whether spontaneous or evoked’’ such as burning, tingling,prickling, itching which is not pleasant.
 On the other hand, dysesthesia is preferentiallyused for an abnormal sensation,that is considered unpleasant.
 Two principal mechanismsare responsiblefor the damage of the nerve: the chemicalneurotoxicity ofthe components of the
endodontic paste and/or the mechanical pressureexertedby the filling materialforced into the mandibular canal.
 The most common fillingmaterials associated with such complicationare cementsmostly contain paraformaldehyde.

5.  Inferioralveolar nerve runsin a canal within the mandible usuallynear the apicesof the third molar and, if the molar is
impacted, Sometimes, during the surgical removal of a mandibularthird molar, the inferioralveolarnerve is damaged
leading to impairment of sensationin the lower lip; which is one of the most unpleasant postoperative complications.
 They are most commonly iatrogenic, predominantly post thirdmandibular molar extraction, althoughthey can occur
post dental implant.
 They are closed nerve lesions, and their severity canonly be assessed once the time course between injury and initial
examinationis known, and through repeatedexaminationswith follow-up of recovery.

6. Pre-operative assessment - an attempt to identify the proximity of the impacted tooth to the
inferior alveolar canal. This evaluation is the first stage in assessing the possible
postoperative occurrence of labial sensory impairment
OPG
close proximity of the third mandibular roots to the mandibular canal is a risk factor,
Distant ≥1 mm between the root tips and the mandibular canal
• superimposition of the root tips over the mandibular canal
• mandibular canal diversion
• darkening of the root
• root apices deviation
In addition to an intimate relationship, interruption of the white line of the mandibular canal
has been shown.

7. CT
• direct contact of the mandibular canal and roots
• buccal or lingual position of the mandibular canal compared to the roots
• teardrop or dumbbell shape to the mandibular canal
• absence of mandibular canal cortication

8.  Narrowing of the root -‘If there
is narrowing of the root where
the canal crosses it, it implies
that the greatest diameter of the
root has been involved by the
canal, or that there is deep
grooving or perforation of the
root
Darkening of the root
Usually the density of the root is the same
throughout its length and this is not disturbed
when the images of the tooth and inferior
alveolar canal overlap.
When there is impingementof the canal on the
tooth root, there is loss of density of the root
,the root appears darker
Deflected roots
Deflectedroots or roots hooked around the canal
are seen as an abrupt deviation of the root, when it
reaches the inferioralveolar canal
The root may be deflectedto the buccal or lingual
side or to both sides so that it may completely
surround the canal or it may be deflectedto the
mesial or distal aspect.

9.  Dark and bifid root This sign appears when the inferior alveolar canal crosses the apex and is identified by the double
periodontal membrane shadow of the bifid apex.
 Interruption of the white line(s) The white lines are the two radio-opaque lines that constitute the ‘roof’ and ‘floor’ of the
inferior alveolar canal. These lines appear on a radiograph due to the rather dense structure of the canal walls
 The white line is considered to be interrupted if it disappears immediately before it reaches the tooth structure either one or both
lines may be involved.

10.  Extra-orally the affectedarea was bounded mediallyby the midline and laterallyby a line extending downward and
slightly backward from the corner of the mouth to the inferior border of the mandible which forms the inferior
boundary
 The extent of sensory loss may vary from a small area, frequently thevermilionborder, to involvement ofall of the
skin innervated bythe mental nerve
 Intra-orally the affectedareas were the inner surface of the lip, the adjacent labial mucosa of the alveolar process
and the mandibularteeth of the affectedside Each patientwas examined onthe first postoperative dayand again at a
follow-up appointment 7 to 10 days later. Sensationwas assessed using cotton wool, blunt probe and pin prick

11.  Several different pattems of onset and development of sensory loss were recognised.
(a) Paraesthesiaof the lip was detectable several hours after surgery. This was rarely profound and most often unilateral.
Recovery was quite common by the next day. Recoverywas usuallycomplete within 4 weeks. Full recoveryof
normal sensationhad occurred within a 4 week period.
(b) Most of the patientswho complained ofa numb lip were aware of the problem immediately after theoperation.
Some reportedthat the anaesthesia was more dense by the first post-operative day and all were unaware of any
improvementwhen seen at the first post-operative visit. Recovery from this injurywas usually complete in about 3
to 4 months.

12.  In several of the patientswho had a sensory deficit for 3 to 6 months. The margin of normal sensation ‘advanced’from the
angle of the mouth so that the area of alteredsensationbecame smallerand the residual defect was near the mid-line.
 In a few of the cases with a prolonged defect, another patternof recoverycould be detected. The intensity of the impairment
was slow to change but not only did the proximal margin of the lesion but also the distal and caudal margins.
 The area of loss therefore became smaller and tended to ‘shrink’ towards the vermillionborder of the lip and towards the
centre of the mental nerve’s territory.

13.  Neurapraxia - describe paralysisin the absence of peripheraldegeneration.
 Axontmesis The essentiallesion is damage to the nerve fibres leadingto peripheral degeneration. The internal
architecture of the nerve is fairly well preserved.
 Neurotmesis This describesa nerve in which all essentialstructureshave been damaged.

14.  First Degree Injury Conduction along the axon is interrupted at the site of injury, there being no break in continuity of
the structures. (neurapraxia)
 Second Degree Injury The axon fails to survive below the level of the injury, for a short distance proximal to it.
(axontmesis)
 Third Degree Injury In additionto axonal disintegrationand Walleriandegeneration, the internal structure ofthe
fasciculi is disorganised.Endoneurial tube continuityis lost and cross-shunting mayoccur.

15.  Fourth Degree Injury The entire fasciculusis involved, all bundles being breachedand disorganised. As the
perineurium and endoneurium are damaged,there may be axon loss and scarring. (neurotmesis)
 Fifth Degree Injury Loss of continuityof the nerve trunk. (neurotmesis)
 Sixth Degree Injury- Functional conduction block, Axon degeneration and endoneurial disruption

16.  Inferior alveolar nerve (IAN) injuries may occur due to mechanical, thermal and chemicalfactors. Compression of the
arterial blood supply of the nerve results in increasedvascular permeability, edema and ischemia.
 Although in traumatic and ischemic injury to IAN, recovery occurs in 85-94% cases over 8 weeks, prolonged
compressioncan cause scarring and fiberdegeneration
 Unlike the lingual nerve, the IAN cannot retracton transectionand the canal wall may act as a conduit for sprouting
axons.
 Injuriesrelated to endodontic treatmentare probablyof neurotoxic origin
 No convincingrecovery is observed after lesions associatedwith endodontictreatment and injectionof local analgesics.

17. Despite the fact that nerve injuries may produce permanent neurosensory damage, clinically reflected
in a loss of function (anesthesia, hypoesthesia), and often accompanied by neurogenic disturbance
(pararesthesia, dysesthesia, allodynia) many cases it demonstrate an impressive potential for at least
partial recovery

18.  To assess the risk of nerve injuryin third molar surgery. RUD, ROODand SHEHABidentifiedradiologicalmarkers to describe the relationshipbetween
the third molar root and the mandibular canal
 ROODand SHEHABfound that diversionof the inferior alveolar canal, darkening of the root with loss of laminadura at the site of over projection of the
canal, and interruptionof the white lineof the mandibular canal were significantlyassociatedwith IAN injuryin third molar surgery.
 POGRELfound that removal of the third molar crown (coronectomy) appears to be a viable technique in those cases where removal of the whole tooth
might put the inferior alveolar nerve at considerable risk of damage.
 The severity of functional impairmentranges from total loss of function(anesthesia) to a mildand transitoryreduction of the tactileand thermalacuity.
Neurogenic discomfortmay be described. Like lingual nerve injuriesreferralsfor IAN injuriesare more common in femalesthan in males.

19.  Ideally,patientsshould be examinedshortly after the injury.
 In most patients,the initial functional status is unknown owing to delayedreferral shows the patternof recovery. There is
a more rapid recovery rate during the first 6 months post-injury thanlater, exactly mirroringthe pattern oflingual nerve
recovery
 In some patients a deterioration ofsensory function overtime due to the formationof a neuroma that interferes with
nerve conduction byintra neural pressure
 The recovery of neurosensoryfunction was relatedto the etiologyof the injury.
 Recovery of lesions associatedwith mandibularthird molar surgery that are of a mechanical nature (compression, crush,
laceration) was significantlybetterthan recoveryin all other etiologies. Serious lesions examinedsoon after the injury
demonstrated an impressive recovery.
 The highestrates of recovery were observedduring the 6 months after injury. The IAN, located in a bony canal, may be
in a favourable positionfor nerve healingand functional regeneration.
 The resultinglesions may be demyelinising axonal lesions or nerve transection,severityof functional impairment ranges
from total loss of function (anesthesia) to a mild and transitoryreductionof the tactile and thermal acuity

20.  When root canal therapy is performed on mandibular teeth posterior to the mental foramen, damage to the inferior alveolar nerve
is possible. Most cases have been reported in connection with the lower second molars
 Mechanical trauma from overinstrumentation into the inferior alveolar canal
 pressure phenomenon from the presence of the endodontic point or sealant within the inferior alveolar canal
 neurotoxic effect from the medicaments used to clean the canal or that are in the sealant.
 Studies have shown that all root canal sealants are neurotoxic to some degree. The most neurotoxic appear to be those containing
paraformaldehyde paste

21. Treatment remains controversial, varyingfrom a wait-and-see approach
 to early,
 not immediate
 surgical débridement ofthe inferior alveolarnerve
 extractionof the tooth
 approachingthe nerve through the socket
 decortication ofthe mandible achievedlaterally from an intraoral and extraoral approach
 sagittalsplittingof the mandibleto expose the nerve within the split.

22.  Acute lesion- excellent recovery isto be expected,but in no less than 3-6 months. An indication ofsome return of
function is the onset of tinglingsensation.The rate of nerve regenerationis taken to be approximately1 mm per day
and regenerationfrom the third molar site to the lip has been calculated to take about 2 months.
 The quality of recoverymay be imperfect if some axons fail to regenerate.
 Chronic lesion Some patientshave permanent sensory loss. Many of them have a poorer qualityof sensation in the
skin of the affected side ofthe lip even after apparent rapid recovery, the conductionvelocities and amplitudesof action
potentials may be severely reduced leadingto qualitativedisturbance.
 Persistent paraesthesia, more noticeablesensory disturbance may be a result of chronic neuropathy

23.  Surgical decompression is the treatment of choice and gives good results when carefully executed (Neary, 1980).
 Surgical exploration of a damaged inferior alveolar nerve certainly must be identified ,The site of injury must be carefully exposed so
that the nerve trunk is not injured again (it may be misplaced).
 External neurolysis will provide a return of sensation in most cases, but care must be taken not to attempt ‘internal neurolysis’ as division
of perineurial sheaths will allow nerve fibres to herniate, and destroy their endoneurial environment (Sunderland, 1978).
 If there is dense scarring throughout the nerve, the affected length of trunk will require excision and a graft will need to be inserted. This
procedure will encourage regeneration but recovery will not be total. If the nerve is found divided, careful suturing is required. Correct
alignment of the fascicles enhances recovery but this microneural repair requires access so that a microscope may be utilised.
 Careful epineurial suture may be undertaken, a graft will be necessary (Emerson, 1981).

24.  Decortication of the mandible in one block of lateral cortex from approximately the second premolar region (posterior to the mental
foramen) to the third molar region. This is carried out in an intraoral approach by using a combination of reciprocating saw and
curved osteotomes.
 In this way, the surgeon can remove the lateral plate as a single piece of bone that can be replaced at the end of the procedure. The
surgeon usually then can identify easily the nerve lying within the substance of the marrow of the mandible. He or she then teases the
nerve out of the inferior alveolar canal, thoroughly cleans the canal and irrigates it of any foreign material examines the root of the
tooth and, if necessary, performs an apicoectomy or even an extraction
 The surgeon then examines the nerve itself in this region, and if sealant is found within the epineurium itself, he or she opens and
cleans the epineurium and irrigates and cleans the individual fascicles. hollowing out the lateral plate of the mandible using acrylic-
type bur is done so that no pressure is placed on the nerve.
 The surgeon then replaces the lateral plate of bone using one or more 1.5-millimeter screws, taking care to avoid further injury to the
nerve.
IMMEDIATE DECOMPRESSION AND DÉBRIDEMENT OF
THE NERVE VIA LATERAL DECORTICATION OF THE
MANDIBLE

25.  Neaverth suggested that a higher incidence of dysesthesia develops in patients in whom the nerve involvement is caused by a root
canal sealant.
 All root canal sealants have the potential to be neurotoxic, and if a radiograph shows sealant to be within the confines of the inferior
alveolar canal, the clinician should monitor the patient carefully during the postoperative period.
 Even if the local anesthetic appears to wear off satisfactorily and sensation returns, clinicians still should follow up patients for 72
hours, because delayed nerve damage caused by less neurotoxic agents
 If symptoms are present as soon as the local anesthetic would be expected to have worn off, the clinician immediately should
perform decompression and débridement, irrigation and cleaning of the nerve, which may achieve the best results.

26.  Motamedi suggested creatinga buccal window, removing the crown followed by sectioningthe roots mesiodistally.
 Pippi advocatedverticalsectioningof the crown of third molar mesiodistallyfollowed by gentle separation ofthe roots.
Another method is coronectomy particularly for vertical, mesioangular and distoangular impactionsin close proximity to
the IAN.
 This involves extractionof the coronal part of the tooth below the cement-enamel junction followed byreduction ofthe
remaining partsat least 3-4 mm below the alveolarcrest. This may permit root migration furtherfrom the nerve, which
may eventually be extracted.
 Complicationsof coronectomy includeneuropraxia, post-operativepain, infectionand failure of the root to migrate
 Signs of IAN compression should be consideredas differential diagnosis among undiagnosedfacial pains particularly
when impactedlower second molars lie in proximityto the nerve

27.  Studies have suggested that in the vast majority of cases when a nerve is affectedabnormallyby local anesthetic,
spontaneousrecoveryoccurs over an eight-week periodestimatedbetween 85 -94 % of such injuries resolve in this way.
 However, another study has suggested that if recovery does not occur quickly, then only about one-third ofthese
patients may go on to experience recoveryand two-thirds of them may have permanent impairment.

29.  48 year old femalepatient was referred to the Departmentof Oral and MaxillofacialSurgery, due to paresthesiaof the left mandibular area after
endodontic treatmentof the leftmandibular second molar.The patient had received endodontic treatmentat a private clinicabout 6 weeks ago.
Conventional radiographs and computed tomography of the mandible showed radiopacityaround the left mandibular canal

30.  After prescribingsteroid medications for 2 weeks, the patientwas sent to the Department of Conservative Dentistry for the
removal of extruded material throughcanal irrigation.
 After the endodontic re-treatment, the patient felt a mild improvement of the paresthesia, neuroplasty and foreign body removal
from the left mandibularcanal under generalanesthesiawas planned.After 2 months, surgical treatment was performed. Surgical
treatment included neurorrhaphy(end to-end reconnectionof nerve tissue), and foreign body removal under general anesthesia
 Under general anesthesia, a corticalbone osteotomywas performed and a monocortical block overlyingthe subapical area of the
second molar was removed. Calcium hydroxide paste was found in the spongious bone, and injured inferior alveolarcanal was
debrided

31. Radiographic view of left mandibular area after surgical intervention. (a) 3 months follow up; (b) 20 months follow up;
 Serper et al. has shown that calcium hydroxide can cause inflammation of the nerves, foreign body reactions and bone necrosis.
 Also, irreversible blockage of nerve conduction may occur when the nerve tissue is exposed to calcium hydroxide for more than 30
minutes. This effect might be caused by the excess quantity of calcium hydroxide which could lead to destabilization of the nerve
membrane potential.
 When extrusion of dental material occurs on the posterior mandibular teeth, the inferior alveolar canal could be damaged since the
distance between the inferior alveolar canal and the apices of the teeth is very short.

32.  The cause of inferior alveolar nerve damage is related to the neurotoxic material.
 In an acute stage, an increasedpermeabilityof vessels can obstruct the blood supply which results in ischemia to nerve
tissue and swelling. Hence, the applicationof tensile force and compressionfor a long period can cause irreversible
damage.
 Neurotoxic effect can be caused by an inflammatory reactionor allergic reaction.These reactions cause action potential
instabilityand reduced nerve conduction.
 According to Serper If the cause were removed within 30 minutes, nerve conductioncould regain stable amplitude this
indicatesthat recoveryfrom damage can be achievedby the early removal of causativefactors.
 When the length of the predictedloss of nerve segment is not too long, the nerve sliding technique canbe the treatment
option. The nerve slidingtechnique has several advantagesover the nerve graft technique ie, betternerve regeneration

34.  21-year-old woman who had undergone endodontictreatmentof her mandibularleft first molar immediately
developedintense pain in the regionof the distributionof the left inferior alveolar nerve and paresthesiawith
formicationafter obturation.
 The canal was obturated with gutta-percha and AH-26 showed root canal filling cement located beyondthe apices of
the tooth with a large extension occupying approximately3 centimetersalong the mandibularcanal.
 The patient’sdentist treated her with antibiotics and NSAIDs and carbamazepine for pain without any improvement.
After 10 days, she was referredby her dentist to our department for evaluation andtreatment.

35.  Clinicalexamination revealed diminished sensation to light touch in the area of the left mental nerve as well as paresthesia with
formication.
 It was decided to decompress the alveolar nerve under general anesthesia by sagittal split osteotomy on the left mandible. The IAN
was identified and the root canal filling was found to be covering the nerve. The 2 valves of the mandible were repositioned and
fixed with 2.0-mm diameter bicortical screws without intermaxillary fixation.
 Radiographs confirmed the satisfactory removal of the endodontic paste from the mandibular canal . The patient reported an
improvement in sensation and paresthesia and the hyposthesia disappeared after 10 days. At 6 months follow-up she became
symptom free.

36.  A 32-year-old male was referred for evaluation of persisting left mandibular pain, paresthesia after root filling of the left
lower wisdom tooth. The dentist had proceeded with the obturation of the tooth with gutta-percha
 The patient returned to his dentist a few days later complaining of pain and the persistent effect of anesthesia.
 He was treated with NSAIDs for several weeks but did not experience any improvement. Six months later, the patient was
finally referred to an oral surgeon, who took a panoramic x-ray, which showed a large amount of radiopaque material
extruding from the root canals of the left inferior third molar
 In spite of the time lapse between the initial treatment and the referral, it was decided to remove the filling material from the
mandibular canal

37.  Exploration of the left IAN was done by sagittal split osteotomy to the left mandible under general anesthesia. The nerve was
cautiously exposed up to the mental foramen. A large amount of paste occupying approximately 2 cm along the mandibular canal
anterior to the apex of the wisdom tooth was delicately removed
 The nerve was found to be covered by the paste debris, which was carefully scraped off the nerve sheath. The 2 valves of the
mandible were repositioned and fixed with 2.0-mm diameter bicortical screws without intermaxillary fixation.
 Radiographs confirmed satisfactory removal of the endodontic paste from the mandibular canal . The patient reported an
improvement in sensation and paresthesia from the first postoperative day. One year after nerve decompression, the patient still
feels a residual hypoesthesia restricted to a very small area of the skin of the left half of the chin but no paresthesia

38.  51-year-old woman chief complaint was severe pain in the left side of the mandible as well as numbness and paresthesiain
her lower right lip and chin. Three weeks before referral, a root canal treatment of the lower left first molar had been
performed under local anesthesiausing a ‘‘home made’’ endodontic paste containingpropolis, zinc phosphate,and clove oil.
 Immediatelyafter obturation, paresthesiaand pain appeared in her lower left lip and chin. The posttreatmentpanoramic
radiographshowed a large overextension of the endodontic fillingmaterial withinthe mandibular canal.The dentist told her
that these symptoms would normallydisappear with time.
 After 3 weeks of treatment with NSAIDs, the patient’s spontaneouspain became more intense and was finally admittedto our
clinic for exploration ofthe right IAN (which was done by sagittalsplit on the left mandible) given the persistenceof her
symptoms.

39.  This was done by sagittal split osteotomyon the left mandible.The nerve was exposed from the apex of the left first
second molar to the mental foramen and was gently freed from the canal.
 Hard cemental debris was found around and within the nerve, which was swollen and surround by granulationtissue
The area was carefullycleaned andthe 2 valves of the mandible were repositionedand fixed with 2.0-mm diameter
bicortical screws without intermaxillaryfixation.
 Radiographsconfirmeda satisfactoryremoval of the endodontic pastefrom the mandibular canal . The patient reported
an improvement in sensationand paresthesia from the first postoperativeday.

40.  Ideally,the fillingmaterial shouldbe limited to the root canal without extendingto periapical tissues
or other neighboring structures. However, overinstrumentation of the root canal with hand or
mechanicallydriven files can perforatethe mandibularcanal, allowing the extrusion ofsealers,
dressing agents, and irrigation solutionsand the passage of microorganismsinto the canal during
endodontic treatment
 Sensory loss or alteration in the territoryof the inferior alveolarnerve, the chin region, and lower
homolateralhalf of the lip is a relativelyinfrequent complication in daily dental practice
 One of the potential iatrogenic causes of this problem is the incorrect treatment of the root canals of
a lower molar or premolar (overextensionand/or overfilling).
 Proximity of the mandibularcanal to the apicesof the premolarand molar teethrequiresa careful
radiographic diagnosiswhen endodontictreatment ofthese teethis planned. An initial pretreatment
radiographof the mandibularteethwill reveal the proximity of the canal to the apices

41.  Preventive measures such as the use of an electronic apex detector,the application of a good apical stop, or moderate condensation
will help avoid overfillingor overextending theendodontic material, also ensure the correct working length but also prevent
perforation ofthe canal and possible subsequent damageto the inferior alveolar nerve resulting from the endodontic treatment
 Experimental studies have shown that eugenol and paraformaldehyde arethe main materials causingneurotoxic reactions. The
irrigationsolutions, such as sodium hypochlorite and ethylenediaminetetraaceticacid (EDTA), might leak into the canal and damage
the nerve chemically.
 AH Plus can cause cytotoxic effectswhen extruded intothe mandibularcanal . Moreover, it has been shown that its component
bisphenol A can cause cytotoxiceffect

42.  The separated instrument cancause nerve compressionand lead to acute neurologicalsymptoms as in our case, the patient
had severe pain. In such cases, retrieval offoreign body from the inferior alveolarcanal becomes mandatory. Removal of
foreignbody from the inferior alveolarcanal is necessaryfor the complete recovery ofnerve sensationsand a better
prognosis, if performedearly.
 If the displaced instrument isin the regionposteriorto mandibularsecond premolar, saggitalsplit osteotomy can be carried
out, while in the regionanteriorto it, a lateral decompressiontechnique hasto be followed.
 Saggital split osteotomy,to remove the displaced endodonticmaterialsfrom the inferior alveolar canal, enablesa
considerable length of nerve to be exposed; damageof the nerve can be readily assessedand the presenceand position of
any toxic substances .
 Lateral decompressioncarriesthe risk of inferior alveolarnerve trauma and hence can lead to temporaryto permanent
neural deficit. Moreover, both saggitalsplit osteotomy and lateraldecompressionhave to be carriedout under general
anesthesia

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