Sunteți pe pagina 1din 9

Clinical Anatomy of the Lingual

Nerve: A Review
Somsak Sittitavornwong, DDS, DMD, MS,* Michael Babston, DMD, MD,y
Douglas Denson, DMD, MD,z Steven Zehren, PhD,x and Jonathan Friend, MSk
Purpose: Knowledge of lingual nerve anatomy is of paramount importance to dental practitioners and
maxillofacial surgeons. The purpose of this article is to review lingual nerve anatomy from the cranial base
to its insertion in the tongue and provide a more detailed explanation of its course to prevent procedural
nerve injuries.
Materials and Methods: Fifteen human cadavers from the University of Alabama at Birmingham School
of Medicines Anatomical Donor Program were reviewed. The anatomic structures and landmarks
were identified and confirmed by anatomists. Lingual nerve dissection was carried out and reviewed on
15 halved human cadaver skulls (total specimens, 28).
Results: Cadaveric dissection provides a detailed examination of the lingual nerve from the cranial base
to tongue insertion. The lingual nerve receives the chorda tympani nerve approximately 1 cm below the
bifurcation of the lingual and inferior alveolar nerves. The pathway of the lingual nerve is in contact with
the periosteum of the mandible just behind the internal oblique ridge. The lingual nerve crosses the
submandibular duct at the interproximal space between the mandibular first and second molars. The sub-
mandibular ganglion is suspended from the lingual nerve at the distal area of the second mandibular molar.
Conclusion: A zoning classification is another way to more accurately describe the lingual nerve based
on close anatomic landmarks as seen in human cadaveric specimens. This system could identify particular
areas of interest that might be at greater procedural risk.
Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial
Surgeons
J Oral Maxillofac Surg 75:926.e1-926.e9, 2017

The mandibular division of the trigeminal nerve is a during routine oral surgical procedures, including
sensory and motor nerve descending through the inferior alveolar nerve block injection, lingual flap
foramen ovale. It carries general sensory branches retraction, and third molar removal.3-11 The aim of
to the oral cavity, face, and ears. The course of the this study was to further break down the lingual
lingual nerve from the cranial base to its insertion nerve into zones based on anatomic landmarks.
into the tongue has been well described.1,2 Given the variability of the position of the lingual
However, this well-known pathway does not seem nerve from person to person, a detailed description
to prevent lingual nerve injury during head and of its average descent from the cranial base to the
neck surgery, specifically as it relates to oral and tongue and surrounding anatomic structures in
maxillofacial surgery. Multiple studies have cited each zone could provide the clinician with more
the incidence of lingual nerve injury encountered information to avoid injuring the nerve.

Received from the University of Alabama at Birmingham, Address correspondence and reprint requests to Dr Sittitavorn-
Birmingham, AL. wong: Department of Oral and Maxillofacial Surgery, University of
*Associate Professor, Department of Oral and Maxillofacial Alabama at Birmingham, 419 School of Dentistry Building, 1919
Surgery. 7th Avenue South, Birmingham, AL 35294-0007; e-mail: sjade@uab.
yResident, Department of Oral and Maxillofacial Surgery. edu
zResident, Department of Oral and Maxillofacial Surgery. Received September 7 2016
xProfessor, Cell, Development and Integrative Biology. Accepted January 10 2017
kProgram Coordinator, Gross Anatomy Laboratory and Surgical Published by Elsevier Inc on behalf of the American Association of Oral and
Laboratory. Maxillofacial Surgeons
Conflict of Interest Disclosures: None of the authors have any 0278-2391/17/30078-2
relevant financial relationship(s) with a commercial interest. http://dx.doi.org/10.1016/j.joms.2017.01.009

926.e1
SITTITAVORNWONG ET AL 926.e2

Materials and Methods Results


Dissections were performed on 15 human cadaveric After the mandibular division of the trigeminal
specimens from the University of Alabama at Birming- nerve passes through the oval foramen, it gives off
ham School of Medicines Anatomical Donor Program. the auriculotemporal, inferior alveolar, and lingual
Donors ranged in age from 67 to 105 years at the time nerves in the infratemporal fossa (Fig 1). The lingual
of death. Nine donors were female and 6 were male. and inferior alveolar nerves descend on the medial
All donors were Caucasian. Cause of death was not aspect of the lateral pterygoid muscle. As 2 separate
noted in this study. Inclusion criteria included the branches, the auriculotemporal nerve courses and sur-
presence of mandibular second molars. All specimens rounds the middle meningeal artery and then merges
were noted to be dental Angle Class I. The exclusion to form a single nerve. The lingual nerve receives the
criterion was a previously cut mandibular ramus chorda tympani approximately 1 cm below the bifur-
(before dissections). cation of the lingual and inferior alveolar nerves. In
The anatomic structures and landmarks were identi- this vicinity, the maxillary artery arches around the
fied and confirmed by anatomists. Dissections were medial aspect of the mandibular condylar neck and
performed by primary and secondary investigators in gives off the middle meningeal artery. After branching
the same fashion. The lingual anatomic structures off the maxillary artery in the infratemporal fossa, the
and pathway were approached from the medial aspect middle meningeal artery ascends just behind the infe-
of the mandible covering an area from the skull base to rior alveolar nerve and runs through the loop of the
the floor of the mouth. auriculotemporal nerve. The middle meningeal artery
A mucosal incision was made in the floor of the continues its upward direction lateral to the chorda
mouth on the side to be dissected. Blunt dissection tympani before passing through the foramen spino-
was performed while preserving the lingual nerve. sum to supply the dura mater.
The lingual nerve was located at its distal end. It After the lingual nerve separates from the inferior
was followed posteriorly to the medial pterygoid alveolar nerve at the superomedial part of the lateral
muscle. The muscle was cut to expose the lingual pterygoid muscle, the lingual nerve continues its pro-
nerve and inferior alveolar nerve more proximally. gression inferiorly. Before the lingual nerve reaches
Dissections were carried out to the cranial base to the inferior border of the lateral pterygoid muscle,
expose the lingual nerve along its length. Other the chorda tympani nerve joins the lingual nerve
notable landmarks included the chorda tympani from a posterior direction (Fig 1).12,13 At the level of
nerve, lingula, ascending mandibular ramus, poste- the opening of the mandibular foramen containing
rior mandibular border, second mandibular the inferior alveolar nerve and artery, the lingual
molar, mylohyoid muscle, submandibular duct, and nerve is approximately 1 cm in front of the
submandibular ganglion. mandibular foramen (Fig 2).

FIGURE 1. Medial view of the mandibular branch of the trigeminal nerve and the maxillary artery.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e3 CLINICAL ANATOMY OF THE LINGUAL NERVE

FIGURE 2. The lingual nerve is approximately 1 cm in front of the mandibular foramen. a, Distance from the lingual nerve to the lingula of the
mandible; asterisk, lingula of the mandible.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.

The lingual nerve passes downward between the The lingual nerve makes a turn in an anteromedial
ramus of the mandible and the medial pterygoid direction at the posterior attachment of the mylohyoid
muscle, crossing the muscle approximately one muscle to the mandible (Fig 5). The lingual nerve en-
third the distance from its origin to its insertion ters the mouth by passing beneath the lower border
(Fig 3). From the medial view, the lingual nerve of the superior constrictor muscle. At this point, the
courses behind the medial pterygoid muscle and nerve is below and behind the third molar. It is usually
re-emerges at the anterior border. As it passes down- in contact with the periosteum of the mandible or the
ward, the lingual nerve is in contact with the perios- upper surface of the mylohyoid. The lingual nerve
teum of the mandible and is posteroinferior to the courses anteriorly just superior to the mylohyoid
internal oblique ridge and parallel to the anterior muscle within the floor of the mouth. The lingual
border of the mandibular ramus (Fig 4). nerve can be found between the sublingual and

FIGURE 3. Medial view shows the lingual nerve crossing the medial pterygoid muscle approximately one third the distance from its origin to its
insertion.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e4

FIGURE 4. Medial view shows the lingual nerve in contact with the periosteum of the mandible just behind the internal oblique ridge.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.

submandibular glands. At the distal aspect of the the mouth above the submandibular gland and below
mandibular second molar, the submandibular ganglion the lingual nerve.
can be found connected inferiorly to the lingual nerve The lingual nerve descends in an arch to the
(Fig 6). The submandibular ganglion is in the floor of inferior surface of the tongue. It loops around the

FIGURE 5. Medial view shows the lingual nerve coursing anteriorly just superior to the mylohyoid muscle.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e5 CLINICAL ANATOMY OF THE LINGUAL NERVE

FIGURE 6. Medial view shows the submandibular ganglion suspended from the lingual nerve at the distal area of the second mandibular
molar.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.

submandibular duct laterally and medially before sup- nerves. To more specifically describe the lingual
plying sensory fibers to the anterior two thirds of the nerve, the authors propose a new description based
tongue (Fig 7). on anatomic zones (Fig 8). The goal is to aid in iden-
tifying potential cases at high risk for lingual nerve
injury. In those cases with existing nerve injury, it
Discussion
can aid in the identification of the level of injury, pro-
After the mandibular division of the trigeminal vide diagnostic information that might aid in surgical
nerve passes through the foramen ovale, it subdivides repair, and help establish a prognostic index.
further into several sensory and motor branches. A description of these zones is provided (Fig 9).
Among these are the inferior alveolar and lingual Zone 1 extends from the skull base superiorly to the

FIGURE 7. Medial view shows the lingual nerve coursing anteriorly and crossing the submandibular duct at the interproximal space between
the mandibular first and second molars.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e6

courses anteromedially, crossing the inferior alveolar


nerve and running along the inferior border of the
lateral pterygoid muscle. It is in this first division of
the maxillary artery that interaction with the lingual
nerve (or inferior alveolar nerve) could pose serious
risk for vascular injury.
Zone 1 also is where the connection of the chorda
tympani nerve with the lingual nerve occurs
(Fig 1).13 This anastomosis occurs approximately 1
to 2 cm below the base of the skull slightly above
the lower border of the lateral pterygoid muscle.12
Erdogmus et al1 stated the average distance of the junc-
tion of the lingual nerve and the chorda tympani from
the foramen ovale was 15.1  5.8 mm. The chorda
tympani carries taste sensation to the anterior two
thirds of the tongue and parasympathetic innervation
FIGURE 8. Zones of the lingual nerve pathway are based on rela- to the submandibular and sublingual salivary
tive anatomic positions. glands.14,15 Kahle and Frotscher16 reported the
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J preganglionic parasympathetic fibers to the subman-
Oral Maxillofac Surg 2017. dibular ganglion begin from the superior salivatory
nucleus. They travel in the facial nerve (intermediate
lingula inferiorly. Zone 2 extends from the lingula nerve) and depart the facial nerve with the taste fibers
superiorly to the junction of the internal oblique ridge in the chorda tympani.16 The chorda tympani joins the
and mylohyoid line inferiorly. Zone 3 extends from the lingual nerve and extends into the floor of the mouth.
inferior extent of zone 2 superiorly to the tongue It contains taste fibers for fungiform papillae on the
inferiorly. anterior two thirds of the tongue and presynaptic
Based on the authors dissections, zone 1 poses the secretomotor fibers for the submandibular and
highest risk for serious vascular injury given the close sublingual glands.16
proximity of the maxillary artery (Fig 1). This artery In Zone 1, aberrant connections between the infe-
originates slightly posterior to the condylar neck. It rior alveolar nerve and lingual nerve were noted in

FIGURE 9. Zone 1 is the lingual nerve pathway from the skull base to the lingula, zone 2 is the lingual nerve pathway from the lingula to the
junction of the internal oblique ridge and mylohyoid line (plus sign), and zone 3 is the lingual nerve pathway from the junction of the internal
oblique ridge and mylohyoid line to the peripheral nerve end supplying the tongue. Asterisk, lingula of the mandible.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
926.e7 CLINICAL ANATOMY OF THE LINGUAL NERVE

FIGURE 10. The submandibular ganglion is usually located at the distal area of the mandibular second molar. #, Crossing location of the
submandibular duct and lingual nerve.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.

many of the authors dissections. Erdogmus et al1 from an inferior alveolar nerve injection; incision,
reported 4 furcation patterns of the lingual and the intubation, and general anesthesia; lingual flap
inferior alveolar nerves based on their positions. A retraction; bone removal and instrumentation; tooth
type I bifurcation was described as above the level of sectioning; tooth elevation; and suturing.5,6 The
the mandibular notch and was observed in 66.7% of lingual nerve has been found 10 to 17.6% of the time
specimens (Fig 9).1 at the level of the alveolar crest or higher at the
Extraction of mandibular third molars is one of the mandibular third molar.17-19 Kiesselbach and
most frequently performed procedures in oral and Chamberlain17 reported the lingual nerve contacted
maxillofacial surgery. The reported prevalence of dam- the lingual plate of the third molar in 62% of 256 pa-
age to the lingual nerve varies from almost 0 to 23%.3,4 tients. The vertical path of the internal oblique ridge
The etiologic factors of lingual nerve damage in curves horizontally at the retromolar area. At this re-
mandibular third molar surgery could be trauma gion, Pogrel et al18 reported the mean vertical distance

FIGURE 11. The submandibular duct courses anteromedially superior to the mylohyoid muscle. #, Crossing location of the submandibular duct
and lingual nerve.
Sittitavornwong et al. Clinical Anatomy of the Lingual Nerve. J Oral Maxillofac Surg 2017.
SITTITAVORNWONG ET AL 926.e8

from the crest of the lingual plate was 8.32 mm and the at the interproximal space between the mandibular
closest distance of the nerve to the lingual aspect of first and second molars (Figs 7, 10, 11).
mandible was 3.45 mm (range, 1 to 7 mm). These find- Limitations to the study relate to demographics and
ings would help clinicians avoid lingual nerve damage technique. All cadaveric specimens were at least
during surgery. These results document the vulnera- 67 years of age. Younger specimens might offer slightly
bility of the lingual nerve as it passes medially to the different quantitative results. In addition to age, all
mandibular third molar. specimens were Caucasian.
The incidence of lingual nerve damage after For technique, 5 investigators performed the dissec-
third molar removal has been reported at 0.2 to tions. Clinical measurements were calibrated but sub-
1.6%.7-10,20,21 Lingual flap elevation and retraction, ject to subtle variation because of the nature of
which engages the internal oblique ridge, with a dissection out of the fascial planes. The major limita-
broad retractor might be a suitable technique to tion of the study is disturbance of the native anatomic
remove the lower third molars. However, the lingual course of the nerve from disruption of fascial planes
elevator and retractor can be placed or migrate too during dissection.
deeply. They can go down far enough to affect the Thorough knowledge of lingual nerve anatomy is of
lingual nerve. Baqain et al22 reported patients were critical importance to all practitioners performing
23 times more likely to sustain transient neurosensory procedures in the oral cavity. The zoning classification
damage to the lingual nerve when lingual tissues were offered by this article can aid in identification,
retracted, and they had a 7 times greater risk with diagnosis, treatment, and prognosis of lingual nerve
major bleeding into the socket during surgery. The aberration and pathology.
retraction of the lingual flap can cause injury to the
lingual nerve. The literature reports temporary lingual
nerve deficit of 1.6 to 9.1%.22-24 References
Zone 2 presented one very obvious finding: in each
1. Erdogmus S, Govsa F, Celik S: Anatomic position of the lingual
of the 28 cadaver hemisections, the lingual nerve was nerve in the mandibular third molar region as potential risk
noted to cross the medial pterygoid muscle at the junc- factors for nerve palsy. J Craniofac Surg 19:264, 2008
tion of the superior one third (near its attachment to 2. Bokindo IK, Butt F, Hassanali J: Morphology and morphometry of
the lingual nerve in relation to the mandibular third molar. Open
the lateral pterygoid plate) and inferior two thirds J Stomatol 5:6, 2015
(Fig 3). In this zone, the pathway of the lingual nerve 3. Chiapasco M, De Cicco L, Marrone G: Side effects and complica-
is in contact with the periosteum of the mandible tions associated with third molar surgery. Oral Surg Oral Med
Oral Pathol 76:412, 1993
just behind the internal oblique ridge (Figs 4, 5). 4. Middlehurst RJ, Barker GR, Rood JP: Postoperative morbidity
Dissection of zone 3 presented 2 important with mandibular third molar surgery: A comparison of two
anatomic findings. The first was the relation of the sub- techniques. J Oral Maxillofac Surg 46:474, 1988
5. Gulicher D, Gerlach KL: Sensory impairment of the lingual and
mandibular ganglion to the mandibular second and inferior alveolar nerves following removal of impacted mandib-
third molars (Figs 6, 10).13 Second, the ganglion rests ular third molars. Int J Oral Maxillofac Surg 30:306, 2001
on the hyoglossus muscle at the posterior edge of 6. Valmaseda-Castellon E, Berini-Aytes L, Gay-Escoda C: Lingual
nerve damage after third lower molar surgical extraction. Oral
the mylohyoid muscle. There it is suspended from Surg Oral Med Oral Pathol Oral Radiol Endod 90:567, 2000
the lingual nerve by 2 filaments. The previous under- 7. Rud J: Reevaluation of the lingual split-bone technique for
standing of the location of this ganglion did not appre- removal of impacted mandibular third molars. J Oral Maxillofac
Surg 42:114, 1984
ciate the close proximity of this vital structure to 8. Goldberg MH, Nemarich AN, Marco WP II: Complications after
the mandibular third molar. Therefore, if the subman- mandibular third molar surgery: A statistical analysis of 500
dibular ganglion is injured by retraction, dissection, consecutive procedures in private practice. J Am Dent Assoc
111:277, 1985
cautery, etc, then this could affect the secretomotor 9. Schwartz LJ: Lingual anesthesia following mandibular odontec-
fibers for the submandibular and sublingual glands.16 tomy. J Oral Surg 31:918, 1973
In zone 3, a dental correlation was made between 10. Fielding AF, Rachiele DP, Frazier G: Lingual nerve paresthesia
following third molar surgery: A retrospective clinical study.
the lingual nerve and the submandibular duct. The Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84:345, 1997
duct originates from the gland for which it was named 11. Morris CD, Rasmussen J, Throckmorton GS, et al: The anatomic
at the posterior edge of the mylohyoid muscle. The basis of lingual nerve trauma associated with inferior alveolar
block injections. J Oral Maxillofac Surg 68:2833, 2010
duct courses anteromedially superior to the mylo- 12. Lata J, Tiwari AK: Incidence of lingual nerve paraesthesia
hyoid muscle and is crossed laterally by the lingual following mandibular third molar surgery. Natl J Maxillofac
nerve at the posterior aspect of the sublingual gland Surg 2:137, 2011
13. Kulczynski B, Wozniak W: Variation of the origin and course of
(Figs 7, 11). As the lingual nerve courses anteriorly, it the chorda tympani. Folia Morphol (Warsz) 37:237, 1978
again crosses the submandibular duct, this time 14. Lehman CD, Bartoshuk LM, Catalanotto FC, et al: Effect of anes-
medially, just before entering the tongue. In each thesia of the chorda tympani nerve on taste perception in
humans. Physiol Behav 57:943, 1995
cadaveric hemisection, the point at which the lingual 15. Doty RL, Heidt JM, MacGillivray MR, et al: Influences of age,
nerve first crossed the submandibular duct occurred tongue region, and chorda tympani nerve sectioning on signal
926.e9 CLINICAL ANATOMY OF THE LINGUAL NERVE

detection measures of lingual taste sensitivity. Physiol Behav 20. van Gool AV, Ten Bosch JJ, Boering G: Clinical consequences of
155:202, 2016 complaints and complications after removal of the mandibular
16. Kahle W, Frotscher M: Color Atlas of Human Anatomy. Vol 3: third molar. Int J Oral Surg 6:29, 1977
Nervous System and Sensory Organs. Stuttgart, Germany, 21. Bruce RA, Frederickson GC, Small GS: Age of patients and
Thieme, 2003 morbidity associated with mandibular third molar surgery.
17. Kiesselbach JE, Chamberlain JG: Clinical and anatomic observa- J Am Dent Assoc 101:240, 1980
tions on the relationship of the lingual nerve to the mandibular 22. Baqain ZH, Abukaraky A, Hassoneh Y, et al: Lingual nerve
third molar region. J Oral Maxillofac Surg 42:565, 1984 morbidity and mandibular third molar surgery: A prospective
18. Pogrel MA, Renaut A, Schmidt B, et al: The relationship of the study. Med Princ Pract 19:28, 2010
lingual nerve to the mandibular third molar region: An anatomic 23. Pogrel MA, Goldman KE: Lingual flap retraction for third molar
study. J Oral Maxillofac Surg 53:1178, 1995 removal. J Oral Maxillofac Surg 62:1125, 2004
19. Miloro M, Halkias LE, Slone HW, et al: Assessment of the lingual 24. Gomes AC, Vasconcelos BC, de Oliveira e Silva ED, et al: Lingual
nerve in the third molar region using magnetic resonance nerve damage after mandibular third molar surgery: A random-
imaging. J Oral Maxillofac Surg 55:134, 1997 ized clinical trial. J Oral Maxillofac Surg 63:1443, 2004

S-ar putea să vă placă și