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British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx

Clinical outcomes of lingual nerve repair

S. Atkins ∗ , E. Kyriakidou
Unit of Oral and Maxillofacial Surgery, School of Clinical Dentistry, University of Sheffield, UK

Accepted 3 July 2020

Abstract

Lingual nerve injury, a well-described complication of third molar removal, may result in permanent lingual sensory deficit leading to symptoms
including lost or altered sensation, inadvertent tongue biting, and the development of unpleasant neuropathic pain, with consequent impaired
quality of life. We analysed outcomes of a prospective case series to determine whether direct anastomosis of the lingual nerve results in
improved sensory recovery and reduced neuropathic pain, and whether delayed surgery is worthwhile. In 114 patients who underwent nerve
repair at our nerve injury clinic following damage sustained during mandibular third molar removal, sensory deficit was assessed before and
after surgery using a questionnaire and visual analogue scales (VAS) to assess pain, tingling, and discomfort. Neurosensory tests were utilised to
evaluate light touch, pin-prick, and two-point discrimination thresholds. Subjectively, 94% patients felt their sensation had improved following
nerve repair, with significant reductions in the incidence of tongue biting (p < 0.0001), impaired speech (p < 0.0001), and neuropathic pain
(p = 0.0017). Quantitative neurosensory data showed highly significant improvements in light touch, pin-prick, and two-point discrimination
(all p < 0.0001), and VAS scores for pain (p = 0.0145), tingling (p < 0.0025), and discomfort (p < 0.0001) were significantly reduced. Patients
with high levels of pain preoperatively (VAS > 40) showed highly significant reductions in pain (p < 0.0001). No correlation was found between
surgical outcome and patient’s age or delay until surgery. Lingual nerve repair results in good sensory outcomes and significant improvements
in the incidence and degree of neuropathic pain, even when delayed.
© 2020 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

Keywords: case series; delay to surgery; lingual nerve surgery; neuropathic pain; treatment outcome

Introduction also complain of reduced or altered taste, impaired speech, or

unpleasant inadvertent tongue biting, all of which can have a
Injury to the lingual nerve during mandibular third molar serious, detrimental effect on quality of life.6,7 Patients may
removal is a longstanding clinical problem. The lingual nerve experience temporary symptoms following lingual injury, but
runs in close proximity to the third molar, often in contact with those who have no significant resolution by three months are
the lingual cortical plate, making it susceptible to injury by unlikely to recover spontaneously.
a surgical burr.1 The incidence of permanent lingual sensory Lingual nerve injuries may result in neuroma-in-
deficit following wisdom tooth removal is up to 0.6%.2–5 In continuity, or a proximal terminal neuroma with nerve stumps
addition to lost or altered sensation, patients suffering these fully separated. A variety of methods have been utilised
injuries may develop unpleasant neuropathic pain; they may to effect repair: end–end anastomosis, autograft or, more
recently, nerve allograft.8 In-vivo studies have shown that
∗ Corresponding author at: Unit of Oral and Maxillofacial Surgery, School
end–end anastomosis produces the best outcome;9 many
studies have shown that repair by anastomosis results in
of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield
S10 2TA, UK. Tel.: +44 114 215 9371. significantly improved sensation, although assessment lacks
E-mail addresses: [email protected] (S. Atkins), standardisation.10 Intraneural scar formation at the repair site
[email protected] (E. Kyriakidou).

https://doi.org/10.1016/j.bjoms.2020.07.005
0266-4356/© 2020 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

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is a major barrier to recovery, causing a mechanical barrier Sensation on the affected side of the tongue was assessed
that impedes axon regeneration,7,11,12 and suggesting that a preoperatively and postoperatively using a questionnaire cov-
single repair site rather than a graft would result in improved ering inadvertent tongue biting, speech impairment, and
outcome. Nerve allografts are an alternative when the extent experience of tingling (paraesthesia), discomfort, and pain.
of the nerve gap may result in tension on the repair.8,12 Patients quantified their pain, tingling and discomfort on the
Many studies have shown lingual nerve repair to be effec- affected part of the tongue using 100 mm visual analogue
tive for reducing neuropathic pain, and have demonstrated scales (VAS). Patients scored their symptoms on each VAS
that patients with no preoperative pain have not developed from 0 (an absence of symptoms) to 100 (worst pain and
pain following recovery.13–16 It has been postulated that late discomfort imaginable or continuous tingling symptoms).
repairs (more than six months) will not result in a reduc- Patients were further asked to rate their feeling on the injured
tion in pain,17 although several studies have demonstrated side of the tongue on a scale from 0% (no sensation) to 100%
the opposite.14,15,18 There is also debate on the timing of (normal sensation).
repair, and whether late repair is worthwhile.14,19,20 Neurosensory investigations to evaluate light touch and
We therefore asked three main questions: pain (pin-prick) sensation, and two-point discrimination were
undertaken as follows:
1 Does direct anastomosis of the lingual nerve result in
improved sensory recovery? Light touch sensation
2 Does this procedure reduce neuropathic pain in patients
suffering this unpleasant condition? A von Frey hair (20 mN; 2 g) was applied randomly to all
3 Is surgery for the recovery of sensation, or reduction in areas of the tongue. Patients indicated sensation by raising a
pain, worthwhile if it has been delayed? finger, whilst their eyes were closed and tongue protruded.
For quantitative comparison, scores were noted on a four-
This study represents, to our knowledge, the largest num-
point scale (0 = no response, 1 = response at the tip only,
ber of patients undergoing a standardised technique of direct
2 = response in most areas, and 3 = response in all areas with
lingual nerve repair who were assessed by a standardised
no obvious difference from the contralateral side).9,19
protocol.

Pinprick sensation
Patients and methods
The ability to detect pain was assessed on a four-point scale as
above but using a sharp probe with a force of 150 nM (15 g).
This case series comprises 114 patients who were referred to
Patients were asked to indicate only when they felt pain or
our nerve injury clinic and underwent lingual nerve repair by
sharpness.
direct end–end anastomosis. All patients had suffered their
injury as a result of third molar removal or, in five cases, third
molar coronectomy. Patients were assessed preoperatively Two-point discrimination
(2000–2018) and reviewed at approximately four months and
up to one year postoperatively (minimum six months). With the patient’s eyes closed and tongue protruding, metal
All repairs were undertaken by one of a small team of probes ranging from 2 mm to 18 mm apart were drawn
senior surgeons (the first author included) using an identi- 5–10 mm across the surface of both sides of the tongue. The
cal technique, as reported previously.9 Briefly, anastomosis minimum separation consistently reported as two points was
was undertaken under general anaesthesia by means of a lin- recorded as the two-point discrimination threshold. For anal-
gual flap with relieving incision lingual to the first premolar. ysis, where two points could not be discriminated at 18 mm,
Periosteum and scar tissue were carefully dissected under the threshold was recorded as 20 mm.
magnification to identify the nerve. Often, the nerve was com-
pletely transected, but in some cases a neuroma-in-continuity Statistical analysis
was identified. Other findings included bony perforations of
the lingual ridge or cortical plate associated with the area of Data were analysed using Prism 8 (GraphPad Software). The
injury, and significant scar tissue. Sometimes metallic frag- categorical (yes/no) incidence data from the patient ques-
ments were identified within the damaged nerve stumps or tionnaire were compared before and after surgery by means
neuroma (confirmed by histopathology). Central and distal of the McNemar test with continuity correction, using only
stumps were freed, allowing resection of the neuroma, and paired data from patients with both preoperative and post-
microsurgical repair with 8–10 non-resorbable sutures (8/0 operative data. A Wilcoxon matched-pairs signed rank test
Ethilon® , Ethicon). Due to the natural arc of the nerve, direct or a paired Student’s t test, as appropriate, was used to com-
anastomosis was achievable in all cases. All patients received pare quantitative data from patients with both preoperative
prophylactic perioperative and postoperative antibiotics and and postoperative data. Postoperative data were from the last
dexamethasone. visit (minimum of six months). All quantitative data were

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checked for normal distribution and correlations assessed

with Pearson’s correlation coefficient.

Results

This case series reports findings from 114 patients (mean

age 34 years) who underwent lingual nerve repair in our
nerve injury clinic during the years 2000–2018. Nineteen
were excluded from the analysis because of a lack of suffi-
cient postoperative review, giving a dataset of 85% of patients
treated. The delay to surgery from injury ranged from 3 to 67
months (mean 16.1 months).

Questionnaire responses

Subjectively, the vast majority of patients (94%) felt their

sensation had improved postoperatively (postoperative mean
46.9% compared with preoperative mean 18.0%: p < 0.0001).
Following nerve repair, there was a reduced inci-
dence of inadvertent tongue biting (McNemar χ2 (1) = 36.54,
p < 0.0001), impaired speech (McNemar χ2 (1) = 22.40,
p < 0.0001) and neuropathic pain (McNemar χ2 (1) = 9.818,
p = 0.0017) (Table 1). While the incidence of altered taste
also reduced, this was not statistically significant.

Neurosensory tests

Quantitative preoperative and postoperative data for patients’

responses to light touch and pin-prick stimuli, and two-point
discrimination thresholds are shown in Fig. 1.
Patients’ ability to detect light touch (20 mN) on the
affected side of the tongue increased significantly follow-
ing nerve repair, with 70/107 patients (65%) sensitive in
most or all areas postoperatively, compared with only 13/112
patients (12%) before surgery. Sixty-three patients (56%) did
not respond to light touch at all on the affected side before Fig. 1. Sensory data: the level of patients’ responses to light touch stimuli
surgery. The pooled data showed a highly statistically signif- with a 20 mN von Frey hair and pin-prick stimuli of up to 150 mN, and two-
icant postoperative improvement in response to light touch point discrimination thresholds. Scores for light touch and pin-prick stimuli:
0 = no response, 1 = response at the tip only, 2 = response in most areas, and
(p < 0.0001).
3 = response in all areas. Preoperative data are shown in blue and responses
The ability to detect sharpness (pin-prick test) was also at the final postoperative test in red. The differences between preoperative
significantly increased. After surgery, 101/106 patients (95%) and postoperative data were highly statistically significant for all sensory
were sensitive to the pin-prick stimulus in most or all areas of parameters (light touch and pin-prick: both p < 0.0001, Wilcoxon matched-
the affected side of the tongue, compared with only 54/109 pairs signed rank test; two-point discrimination: p < 0.0001, paired Student’s
t test).
(50%) before surgery. Following surgery, 81 patients (76%)
were sensitive in all areas of the affected side of the tongue.
The pooled data showed a highly statistically significant post- threshold 8.77 mm compared with mean preoperative thresh-
operative improvement in response to the pin-prick stimulus old 13.87 mm, p < 0.0001).
(p < 0.0001).
Two-point discrimination thresholds also improved sig- VAS scores
nificantly. While 22 patients were unable to differentiate
two points preoperatively, this improved to only three post In addition to the reduction in the proportion of patients
surgery. The pooled data showed a highly statistically signif- reporting neuropathic pain in the questionnaire, patients’
icant reduction in threshold after surgery (mean postoperative VAS scores for pain, tingling, and discomfort were also

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Table 1
Comparison between responses to questions asked preoperatively and at the final test. Data are number (%).
Question Preoperatively Postoperatively ␹2 statistica p valuea
Inadvertent tongue biting? 92/110 (84) 40/97 (41) 36.54b <0.0001
Taste disturbance? 79/92 (86) 56/75 (75) 2.769c 0.0961
Speech affected? 80/107 (75) 37/93 (40) 22.40d <0.0001
Pain? 52/110 (47) 29/104 (28) 9.818e 0.0017

Data are numbers of patients who responded “yes” out of the total number of patients with a response for that parameter. % data are percentage of patients with
a response, who responded “yes”.
a Chi squared statistic and two-tailed p value from McNemar’s test with continuity correction for data from patients with both preoperative and postoperative

responses (all calculations have one degree of freedom).

b n = 96.
c n = 70.
d n = 91.
e n = 102.

Fig. 2. Mean VAS scores (±SEM) for the level of pain, tingling and discomfort. Patients scored their symptoms on a 100 mm scale from 0 = an absence of
symptoms to 100 = worst imaginable (pain and discomfort) or continuous (tingling) symptoms. Preoperative data are shown in blue and responses at the final
postoperative test in red. There were statistically significant reductions in symptoms postoperatively as assessed by VAS, compared with preoperative levels, for all
three parameters (pain: p = 0.0145; tingling: p < 0.0025; discomfort: p < 0.0001; paired Student’s t test). Post-op = final postoperative test; pre-op = preoperatively;
SEM = standard error of the mean; VAS = visual analogue scale.

reduced postoperatively (Fig. 2). All three symptom measures and/or neuropathic pain, mainly in the form of dysaesthesia
were statistically significantly reduced following lingual or hyperalgesia.
nerve repair (pain: p = 0.0145; tingling: p < 0.0025; discom- There was a significant reduction in tongue biting after
fort: p < 0.0001). In particular, the great majority (79%) of surgery, which is something that patients find particularly
patients with higher (over 40) pain VAS scores preopera- unpleasant; this is likely to be associated with the highly sig-
tively had a large (mean 44.1) reduction in postoperative pain nificant improvement in ability to detect sharpness (pinprick)
(p < 0.0001). postoperatively.
Further, the threshold over which two points could be dis-
criminated was significantly reduced, and the ability to detect
Effects of timing of surgery and patient’s age light touch was improved following surgery. These findings
corroborate the observation that 94% of patients felt subjec-
Any relation between the delay in surgical repair following tively that their sensation had improved, and are in keeping
nerve injury and surgical outcome (as assessed by the differ- with earlier studies.9,14,18,21
ence in discrimination thresholds between the affected and Patients also reported a significant improvement in speech,
unaffected sides of the tongue), and between the patient’s age yet interestingly there was no significant improvement in
at the time of surgery and surgical outcome, was assessed. In taste. This lack of improvement in taste contrasts with the
neither case was there any significant correlation (Fig. 3). study by Robinson et al9 that showed a significant improve-
ment in gustatory function, but correlates with the study by
Riediger et al22 that showed extremely poor recovery of taste
following surgery. Nakanishi et al6 observed a poorer return
Discussion of gustatory function with an increase in delay to surgery,
which may explain why we failed to demonstrate improve-
The majority of patients seen at our nerve injury clinic benefit ment, as many of our patients had a lengthy delay to surgery.
from advice and observation but do not require surgery due to For some patients, lingual nerve injury can cause dysaes-
satisfactory recovery from lingual nerve injury. Lingual nerve thesia, which can have a significant detrimental effect on
repair was undertaken on patients with significant anaesthesia

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Fig. 4. Suggested clinical management pathway for lingual nerve injury.

Fig. 3. Relation between surgical outcome and timing of surgery or patient’s

have demonstrated good outcomes with lengthy delay.6,19,21
age. The final outcome expressed as the difference between the two-point In the present study there was no correlation between delay
discrimination thresholds on the affected and unaffected sides of the tongue to surgery and quality of outcome, and significant improve-
at the final postoperative test, plotted against the delay between nerve injury ments occurred even after lengthy delay (more than three
and surgical repair, and the age of the patient at the time of surgery. No years). One study highlighted a reduced outcome for taste
significant correlation was found between surgical outcome and either delay
to surgery (Pearson’s r = 0.1060; p = 0.2892) or age (Pearson’s r = 0.0046;
with longer delays,6 but with no other adverse outcome,
p = 0.9632). which is in keeping with our results. However, it is our belief
that a more favourable result is likely, with less impact on a
patient’s quality of life, if repair is undertaken earlier (ideally
quality of life.23,24 Some authors have suggested that surgery before six months). It is of concern that patients are often
(especially more than six months after injury) may increase denied early treatment due to a lack of onward referral in
the risk of neuropathic pain25 or lead to no significant an appropriate time. This may be due to lack of follow up,
difference,9 whilst others have shown a reduction in neu- embarrassment, fear of litigation or, in some cases, uncer-
ropathic pain15,16 or even complete resolution.13 Our results tainty over the management of patients with symptoms that
show a significant reduction in the number of patients who indicate nerve injury. Surgeons may also quite reasonably
reported pain postoperatively, and also a reduction in patients’ delay referral whilst any recovery is being monitored, but
VAS scores for pain. This was particularly marked in patients this often leads to significant delay in any potential repar-
with preoperative pain scores of more than 40. ative surgery. We have therefore developed a management
The timing of repair following trigeminal nerve injury is protocol for lingual nerve injuries (Fig. 4) and suggest that it
the subject of much debate. Some surgeons have highlighted should be implemented routinely.
improved outcome with early repair,20 others have shown One criticism of this research may be that 19 patients were
no difference in outcome with delayed repair,14 while others excluded for lack of follow up, and that this may have been

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