## 3 Results
More recently, [PERSON] and [PERSON] [30] assessed the incidence of and spontaneous recovery from lingual nerve injury following surgical techniques: the buccal approach with lingual flap retraction (BA+) and the buccal approach without lingual flap retraction (BA\(-\)). The results indicate a prevalence of permanent LNI of 0.60% for BA+ and 0.20% for BA\(-\), with a temporary LNI prevalence of 0.60% (BA\(-\)) and 6.40% (BA+). In line with [PERSON] and [PERSON]'s findings, they concluded that the use of a lingual nerve retractor during third molar surgery is associated with a higher incidence of temporary and permanent nerve damage. A more recent literature review [39] similarly examines how retracting and safeguarding the lingual flap could influence the occurrence of lingual nerve injury (LNI) during third molar extraction, compared with protocols that do not involve manipulation of lingual tissue. In particular, 11 studies were considered (Table 4). From the literature analysis, the outcomes were compared by analyzing the mean incidence values and standard deviations of lingual nerve injury (LNI) reported by the studies, distinguishing between the sample treated with LF+ (3886 surgeries) and that treated with LF (5938 surgeries). For the LF+ group, the mean incidence of temporary LNI was 2.98 \(\pm\) 0.03%, and for permanent LNI, it was 0.1 \(\pm\) 0.003% (Figure 2). In contrast, the LF group had a mean incidence of 1.92 \(\pm\) 0.02% for temporary injuries and 0.49 \(\pm\) 0.006% for permanent injuries. In contrast to previous literature, and consistent with our study, the findings from this review suggest that the LF+ technique reduces the risk of lingual nerve injury during mandibular third molar extraction. Additionally, retracting the lingual flap improves access to the surgical site, potentially simplifying the procedure. Occasionally, patients may experience paresthesia, likely due to traction pressure from the retractor, but such damage is typically temporary, with full recovery occurring within 2 to 6 months. In agreement with our study, the most recent systematic review and meta-analysis by [PERSON] et al. (2018) examines studies on patients who underwent surgical extraction of the lower third molar using the buccal approach without lingual flap retraction (BA\(-\)) and with lingual flap retraction (BA\(+\)). The incidence of permanent nerve injury was 0.18% with BA\(-\) and 0.07% with BA\(+\). These conclusions contrast the widely held belief that the surgical approach involving only the buccal flap better preserves the integrity of the lingual nerve compared with the LF+ technique. It is clear that the primary challenge in reaching definitive conclusions stems from the multitude of possible interventions, which results in a high number of variables that are nearly impossible to account for simultaneously ([PERSON] et al., 2018). This notion is bolstered by the observation that studies with similar designs frequently present significantly different or conflicting outcomes, indicating unclear management of intervention variables that could potentially pose a risk factor for lingual nerve injury (LNI). One factor that may have contributed to the propagation of the theory, now disproven, that the use of LF+ increases the risk of LNI, is the lack of randomization in the analyzed samples. In several studies, the use of a lingual retractor was left to the clinician's discretion. This practice could have introduced bias since lingual retraction might have been employed more frequently in challenging cases that inherently carried a higher risk of lingual nerve injury (LNI), regardless of whether or not lingual retraction was formally documented. Another limitation was the variability in the type of lingual retractor utilized across articles, with some studies failing to specify the type used. This variability introduced potential bias ([PERSON] et al., 2018; [PERSON] et al., 2018).