Preservation of lower lip sensation directly influences postoperative quality of life in patients undergoing mandibular resection. In standard segmental mandibulectomy, the inferior alveolar nerve (IAN) is sacrificed, resulting in lower lip anaesthesia, which may contribute to difficulties such as drooling, impaired articulation, and unintentional biting of the lip. ^,

Although nerve grafting can be employed to attempt sensory restoration, outcomes are inconsistent. In cases where oncological margins or disease extent do not mandate nerve resection, such as in benign lesions or osteoradionecrosis, preservation of the IAN may be feasible. A nerve-sparing approach during mandibulectomy has previously been described, however, functional outcomes have not been clearly reported. Even in patients presenting with pain or dysaesthesia, symptoms are frequently attributable to chronic infection, inflammation, or fibrotic entrapment of the nerve within necrotic bone, and removal of devitalised bone with release of the nerve from the inferior alveolar canal may provide decompression and symptomatic improvement.

All cases in this series were virtually planned with preoperative computed tomographic imaging to fabricate a patient-specific cutting guide to facilitate safe dissection of the nerve ( Figs. 1 and 2 ). To maximise accuracy and minimise soft tissue injury, piezoelectric surgery was used for the bone cuts and to free the nerve. No intraoperative nerve injuries occurred.

Using digital workflow technology, the inferior alveolar nerve is delineated along its course from the lingula to the mental foramen (left). A virtual surgical cutting guide is then planned in relation to this path, and superimposed on to the mandibular model (right), thereby facilitating greater accuracy of osteotomy cuts intraoperatively.

The figure shows a left-sided segmental mandibulectomy with the preserved intact inferior alveolar nerve (IAN) traversing the bony defect. The nerve can be seen coursing through the resection site prior to inset of the fibular free flap, highlighting its preservation during the surgical procedure.

This case series included five adult patients who underwent nerve-preserving segmental mandibulectomy for Notani grade 3 osteoradionecrosis (ORN) of the mandible with immediate reconstruction with osteocutaneous fibular free flaps.

Objective postoperative sensory evaluation within the distribution of the mental nerve was assessed by a single examiner at their last follow-up visit at four standardised cutaneous points on the lower lip and chin ( Fig. 3 ). Each modality was graded using a three-point ordinal scale: 1 = normal sensation; 2 = altered sensation; 3 = no sensation. Results were compared with the contralateral side which was unaffected in all patients.

The figure shows the extraoral sensory territory tested for the inferior alveolar nerve, including the lower lip and chin on the affected side. These areas correspond to the mental nerve distribution and are illustrated using the canine tooth as a reference point for sensory assessment. Point 1: lip mucosa, lateral to the canine; Point 2: lip mucosa, medial to the canine; Point 3: medial chin skin, medial to the canine; Point 4: lateral chin skin, lateral to the canine.

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