Temporary lip paresthesia during orthodontic molar distalization: Report of a case

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Temporary lip paresthesia during orthodontic molar distalization: Report of a case Giampietro Farronato,a Umberto Garagiola,b Davide Farronato,c Luca Bolzoni,d and Elena Parazzolid Milan, Italy Lip paresthesia during mandibular molar orthodontic distalization is rare. When it occurs, it is often related to excessive dimensions of the mandibular second molar roots. In this clinical report, we describe a patient who developed lip paresthesia during orthodontic treatment. The paresthesia was relieved by immediate interruption of the forces applied to the mandibular second molars and pharmacologic therapy. Before fixed orthodontic treatment proceeds in patients with large tooth roots, it is important to diagnose the relationship between the roots and the mandibular canal to prevent nerve numbness and damage. (Am J Orthod Dentofacial Orthop 2008;133:898-901)

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emporary paresthesia of the lower lip can result from various pathologic conditions, including benign causes and underlying systemic and neoplastic diseases. It can be the only symptom of a compound odontoma in the mental foramen region,1 or it can be associated with metastatic tumors in the mandible.2 It might be the result of orthognathic surgery to the mandible3-6 after endodontic treatment,7,8 or after removal of the mandibular third molar.9,10 Temporary mental paresthesia of the lower lip with a fixed appliance during conventional orthodontic treatment of an adult is a rare complication.11,12 Some authors13-15 have described a few cases of numbness of the lower lip. We report an additional case of such a sensory disturbance. CASE REPORT

A 16-year-old boy came to a private orthodontic office for tooth alignment. His anamnesis was noncontributory, and he had no disease. He went through the usual diagnostic examinations: impressions, intraoral and facial photos, panoramic radiograph, lateral teleradiograph, and cephalometric tracing. The clinical diagnosis was skeletal Class I malocFrom the University of Milan, Milan, Italy. a Professor and chairman, Department of Orthodontics and Gnathology, School of Dentistry, Dental and Stomatologic Clinic, Istituti Clinici di Perfezionamento. b Assistant professor, Department of Oral Surgery and Orthodontics, School of Dentistry. c Lecturer, Department of Oral Surgery and Orthodontics, School of Dentistry. d Lecturer, Department of Orthodontics, School of Dentistry. Reprint requests to: Giampietro Farronato, University of Milan, Università degli Studi di Milano, Clinica Odontoiatrica, via Commenda, 10, Milan, Italy; e-mail, [email protected]. Submitted, June 2006; revised and accepted, September 2006. 0889-5406/$34.00 Copyright © 2008 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2006.09.051

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clusion, dental deepbite with biprotrusion, and vertical growth prediction. The treatment plan suggested 4 premolar extractions, but the patient refused this. Consequently, an alternative treatment was proposed that included the extraction of the mandibular third molars and the placement of a rapid palatal expander and fixed orthodontic appliances to distalize the first and second molars of both arches. During treatment with the fixed appliances, opencoil springs, applied between the first and second mandibular molars to distalize them, were activated periodically. After 6 months of the coil springs being applied, paresthesia developed suddenly, specifically in the area of innervation of the mandibular right nerve. The patient was sent to the Department of Orthodontics of the University of Milan, Italy, for a consultation. After evaluation, a computerized tomography (CT) scan and a panoramic radiograph were requested. The radiologic examinations showed excessive growth and length of the roots of the mandibular second molars, which, with the distalization, led to interference with the mandibular canal and compression of the mandibular nerve (Fig 1). To heal the nerve lesion, the first actions were to remove the coil springs and the bands on the mandibular second molars and grind them to prevent strong contact with their antagonists. In addition, pharmacologic therapy was prescribed, consisting of an anti-inflammatory drug such as serratiopeptidase (Danzen, Takeda, Rome, Italy; 10 mg, orally, 3 times a day for 1 week) and vitamin B (Be-total, Pfizer, Milan, Italy; 100 mg, daily for 10 days). Immediately after removing the coil springs and the bands and grinding the occlusal surfaces of the mandibular second molars, the symptoms started to diminish. They disappeared within 2 weeks, leading to complete recovery. A CT scan 2 months later showed a similar relationship

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Fig 1. Records at symptom onset: A, panoramic radiograph; B and D, CT scans, right side; C and E, CT scans, left side.

between the root apices and the mandibular canal (Fig 2). The original orthodontic alignment treatment was completed, simply avoiding the bands on the second molars and maintaining all other appliances in place. At the end of alignment, a retainer was prescribed. The patient suffered no further paresthesia and recovered completely. DISCUSSION

According to the literature, a close relationship between the mandibular canal and the roots of the first

and second molars, particularly the distal roots, is unusual.11,12 Some authors13-15 described a rare clinical case of a buccal position of the mandibular left second molar roots in an intimate relationship with the mandibular canal. During the alignment and leveling of an extremely lingually inclined tooth, the root apices were moved against the mandibular nerve, causing paresthesia. Usually, the mandibular canal is far buccal to the molar roots and slightly buccal to the premolar toots.16 Closer proximity is seen in ectopic or impacted teeth,

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Fig 2. Two months after recovery: A, panoramic radiograph; B and D, CT scans, right side; C and E, CT scans, left side.

with long or abnormally large roots, and when the mandibular body is not high. When intimate contact occurs between the molar roots and the mandibular canal, the cortical bone that covers the canal can be thin or deficient; this leads to immediate paresthesia if the orthodontic tooth movement invades the mandibular canal.

Lower lip paresthesia as a result of orthodontic treatment is an extremely rare event12,13,15 related to abnormally long roots and close contact with the mandibular canal.16 No specific tests or measurements can predict this risk, and we can state only that the original panoramic radiograph showed unusually and excessively long mandibular second molar roots close

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to the mandibular canal. When mandibular molar distalization is contemplated in treatment, detailed analysis of the panoramic radiograph might be useful to prevent this unusual occurrence. In our case, the panoramic radiograph showed excessively long molar roots near the mandibular canal bilaterally, although the symptoms developed only on the right side.

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