Abstract
The authors present a case of inferior alveolar nerve morbidity attributable to use of bone wax to control haemorrhage during third molar surgery. The patient presented after 11 symptom-free years with parasthesia and, eventually pain in the cutaneous distribution of the right inferior alveolar nerve. Radiographs revealed a 1 cm radiolucency consistent with a neuroma. Pathological examination of the surgically resected lesion revealed a foreign body reaction to bone wax. The case illustrates the poor resorption qualities of bone wax and the need for other haemostatic agents to achieve haemostasis in dentoalveolar surgery.
Bone wax is widely used in craniomaxillofacial surgery to obtain haemostasis from bony structures. It has no inherent haemostatic property but acts by tamponading the marrow spaces. It was first used in surgery by Parker in 1892 and is now routinely used in a variety of operations to control bleeding from the bone. Modern bone wax is composed of 85–90% white beeswax and 10–15% isopropyl palmitate with or without pure paraffin wax . Bone wax is generally a safe material and is relatively innocuous. Adverse reactions are few, but the following have been reported: foreign body granulomatous reactions when used in the nasal cavity, orbit, foot, tooth extraction socket, cerebellopontine angle, vein grafts, mastoid and medulla oblongata . The authors report a case of inferior alveolar nerve damage mimicking a neuroma as a result of using bone wax in third molar surgery.
Case Report
A 29-year-old woman was referred with a 2 month history of paraesthesia affecting the cutaneous distribution of the right mental nerve. The numbness was gradually worsening, resulting in occasional drooling. Her medical history was non-contributory, other than surgical removal of both her lower third molars 11 years prior to the onset of her present symptoms. The details of the operation were not available, but she reported having bilateral mental nerve paraesthesia for 1 month following the removal of her wisdom teeth, which resolved spontaneously and she remained asymptomatic in the intervening period.
Subjective and objective assessment revealed parasthesia in the distribution of the right mental nerve. Radiographic examination showed a radiolucent lesion associated with the right inferior alveolar nerve canal in the region of the right lower third molar. A CT scan of the mandible demonstrated a focal rounded expansion of the right inferior alveolar canal, measuring 9 mm in diameter, posterior to the roots of the second molar tooth. The appearance suggested neuroma of the inferior alveolar nerve causing focal bony expansion of the canal ( Fig. 1 ). The patient’s symptoms worsened over the next 3 months and she experienced pain in the right mandible. Following the onset of pain in the right mental nerve distribution and the CT findings, surgical exploration of the lesion in the right mandible was arranged. The lesion in the right mandible was approached intra-orally via a right sagittal split ramus osteotomy. Intraoperatively, a fusiform swelling of the right inferior alveolar nerve was noted ( Fig. 2 ). On palpation the lesion felt firm and its appearance was consistent with a neuroma. The lesion was excised and the nerve grafted (sural nerve donor site). Following the resection and on dissecting the specimen a large piece of bone wax was removed ( Fig. 3 ). The patient made a good recovery and at the 1-year follow-up was pain free and reported gaining some sensation in the right mental nerve area. Histopathology of the resected soft tissue and the foreign body showed variably disorganised and splaying nerve fascicles with florid haemorrhagic fibrosis containing scattered tiny foreign body granulomas.
