Inferior Alveolar Nerve Impairment Following Third-Molar Extraction: Management of Complications and Medicolegal Considerations

Abstract

Background: Wisdom tooth extraction is a routine procedure with potential complications. In the lower arch, the displacement of a root or its fragment into the submandibular space is a relatively common occurrence that can lead to permanent damage to peripheral nerve fibers. Recent advancements in dental technologies, including CAD-CAM and artificial intelligence, have contributed to improved clinical outcomes in surgical procedures. Methods: Following a brief introductory narrative review, this clinical case describes the extraction of the left third inferior molar, which was sectioned by the oral surgeon to facilitate its removal. The procedure led to the progressive migration of a root fragment into the submandibular space, triggering an infective process. Efforts to retrieve the root fragment resulted in irreversible damage to the somatosensory motor nerves associated with the inferior alveolar nerve after the second surgery was performed by a maxillofacial surgeon. Results: Determining the responsibility for the damage (caused either by the oral or maxillofacial surgeon) involves both technical and ethical considerations, which are particularly relevant in cases involving re-intervention by different specialists. This case highlights the importance of a thorough preoperative evaluation of the patient's anatomical, bone, and dental characteristics. The use of new technologies can significantly reduce the risk of complications that may otherwise lead to permanent damage and complex determinations of professional responsibility. Conclusions: Given the potential, albeit rare, for permanent disturbance of sensory and motor functions, managing complications and assessing the resulting damage are critical and sensitive steps in resolving such case both clinically and legally.

Keywords: alveolar nerve paralysis; head and neck; maxillofacial surgery; oral surgery; post-operative complications; pre-operative assessment; submandibular; third molars; tooth extraction; wisdom teeth.

Figure 1

Initial panoramic radiograph of the patient with both lower wisdom teeth mesially inclined, partially impacted, and in strict contact with the distal wall of the adjacent tooth affected by dental caries.

Figure 2

Panoramic radiograph taken after the lower wisdom teeth extraction, shown on the right side the residual fractured root.

Figure 3

CBCT sagittal and axial views showing the position of the residual fractured root outside the bone in the submandibular space.