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Kämmerer PW, Heimes D, Hartmann A, Kesting M, Khoury F, Schiegnitz E, Thiem DGE, Wiltfang J, Al-Nawas B, Kämmerer W. Clinical insights into traumatic injury of the inferior alveolar and lingual nerves: a comprehensive approach from diagnosis to therapeutic interventions. Clin Oral Investig 2024; 28:216. [PMID: 38488908 PMCID: PMC10942925 DOI: 10.1007/s00784-024-05615-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/10/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES This scoping review explores the risk and management of traumatic injuries to the inferior alveolar and lingual nerves during mandibular dental procedures. Emphasizing the significance of diagnostic tools, the review amalgamates existing knowledge to offer a comprehensive overview. MATERIALS AND METHODS A literature search across PubMed, Embase, and Cochrane Library informed the analysis. RESULTS Traumatic injuries often lead to hypo-/anesthesia and neuropathic pain, impacting individuals psychologically and socially. Diagnosis involves thorough anamnesis, clinical-neurological evaluations, and radiographic imaging. Severity varies, allowing for conservative or surgical interventions. Immediate action is recommended for reversible causes, while surgical therapies like decompression, readaptation, or reconstruction yield favorable outcomes. Conservative management, utilizing topical anesthesia, capsaicin, and systemic medications (tricyclic antidepressants, antipsychotics, and serotonin-norepinephrine-reuptake-inhibitors), proves effective for neuropathic pain. CONCLUSIONS Traumatic nerve injuries, though common in dental surgery, often go unrecorded. Despite lacking a definitive diagnostic gold standard, a meticulous examination of the injury and subsequent impairments is crucial. CLINICAL RELEVANCE Tailoring treatment to each case's characteristics is essential, recognizing the absence of a universal solution. This approach aims to optimize outcomes, restore functionality, and improve the quality of life for affected individuals.
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Affiliation(s)
- Peer W Kämmerer
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany.
| | - Diana Heimes
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Amely Hartmann
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Marco Kesting
- Department of Oral and Cranio-Maxillofacial Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glückstraße 11, 91054, Erlangen, Germany
| | - Fouad Khoury
- International Dental Implant Center, Private Clinic Schloss Schellenstein, Am Schellenstein 1, 59939, Olsberg, Germany
| | - Eik Schiegnitz
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Daniel G E Thiem
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Jörg Wiltfang
- Department of Oral and Maxillofacial Surgery, Christian Albrechts University, UKSH Campus Kiel, 24105, Kiel, Germany
| | - Bilal Al-Nawas
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Wolfgang Kämmerer
- Pharmacy Department, University of Augsburg, Medical Faculty, D-86156, Augsburg, Germany
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Al-Haj Husain A, Schönegg D, Valdec S, Stadlinger B, Gander T, Essig H, Piccirelli M, Winklhofer S. Visualization of Inferior Alveolar and Lingual Nerve Pathology by 3D Double-Echo Steady-State MRI: Two Case Reports with Literature Review. J Imaging 2022; 8:jimaging8030075. [PMID: 35324630 PMCID: PMC8954741 DOI: 10.3390/jimaging8030075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 01/25/2023] Open
Abstract
Injury to the peripheral branches of the trigeminal nerve, particularly the lingual nerve (LN) and the inferior alveolar nerve (IAN), is a rare but serious complication that can occur during oral and maxillofacial surgery. Mandibular third molar surgery, one of the most common surgical procedures in dentistry, is most often associated with such a nerve injury. Proper preoperative radiologic assessment is hence key to avoiding neurosensory dysfunction. In addition to the well-established conventional X-ray-based imaging modalities, such as panoramic radiography and cone-beam computed tomography, radiation-free magnetic resonance imaging (MRI) with the recently introduced black-bone MRI sequences offers the possibility to simultaneously visualize osseous structures and neural tissue in the oral cavity with high spatial resolution and excellent soft-tissue contrast. Fortunately, most LN and IAN injuries recover spontaneously within six months. However, permanent damage may cause significant loss of quality of life for affected patients. Therefore, therapy should be initiated early in indicated cases, despite the inconsistency in the literature regarding the therapeutic time window. In this report, we present the visualization of two cases of nerve pathology using 3D double-echo steady-state MRI and evaluate evidence-based decision-making for iatrogenic nerve injury regarding a wait-and-see strategy, conservative drug treatment, or surgical re-intervention.
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Affiliation(s)
- Adib Al-Haj Husain
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, 8032 Zurich, Switzerland; (A.A.-H.H.); (S.V.); (B.S.)
| | - Daphne Schönegg
- Clinic of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland; (D.S.); (T.G.); (H.E.)
| | - Silvio Valdec
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, 8032 Zurich, Switzerland; (A.A.-H.H.); (S.V.); (B.S.)
| | - Bernd Stadlinger
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, 8032 Zurich, Switzerland; (A.A.-H.H.); (S.V.); (B.S.)
| | - Thomas Gander
- Clinic of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland; (D.S.); (T.G.); (H.E.)
| | - Harald Essig
- Clinic of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland; (D.S.); (T.G.); (H.E.)
| | - Marco Piccirelli
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland;
- Correspondence: ; Tel.: +41-44-253-83-96
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Andrade-González RD, Perrusquia-Hernández E, Montes-Ángeles CD, Castillo-Díaz LA, Hernández Campos ME, Pérez-Martínez IO. Encoding signs of orofacial neuropathic pain from facial expressions in mice. Arch Oral Biol 2022; 135:105369. [DOI: 10.1016/j.archoralbio.2022.105369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/02/2022]
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Weyh A, Pucci R, Valentini V, Fernandes R, Salman S. Injuries of the Peripheral Mandibular Nerve, Evaluation of Interventions and Outcomes: A Systematic Review. Craniomaxillofac Trauma Reconstr 2021; 14:337-348. [PMID: 34707795 PMCID: PMC8543599 DOI: 10.1177/19433875211002049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Trigeminal nerve injuries are common and there is currently no consensus on both timing and type of intervention to achieve the best outcomes. A systematic review was performed to compare the outcomes of the many different types of therapeutic interventions for nerve injury. PubMed, EBSCO, and Cochrane Review databases were used to search for studies published from January 1, 2000 to December 31, 2019. Included studies detailed treatment of an injury to peripheral branches of the trigeminal nerve, either known transection or injury causing persistent alteration in sensation. The primary outcome was functional sensory recovery via the Medical Research Council scale. Twenty studies were included, detailing outcomes of 608 subjects undergoing intervention for 622 nerve injuries. Surgical interventions were able to achieve functional sensory recovery in approximately >80% or more of the subjects. There was heterogeneity among how procedures were performed, timing to intervention, and methods of measuring recovery. The data of this study supports the ability of surgical intervention to achieve functional sensory recovery in a significant number of subjects, and found evidence for better outcomes with intervention closer to the time of injury.
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Affiliation(s)
- Ashleigh Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Resi Pucci
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy
| | - Valentino Valentini
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy
| | - Rui Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Salam Salman
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
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Calotta NA, Kuzon W, Dellon AL, Monstrey S, Coon D. Sensibility, Sensation, and Nerve Regeneration after Reconstructive Genital Surgery: Evolving Concepts in Neurobiology. Plast Reconstr Surg 2021; 147:995e-1003e. [PMID: 34019514 DOI: 10.1097/PRS.0000000000007969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sensory recovery following phalloplasty and vaginoplasty for gender dysphoria is essential to the overall success of gender-confirming surgery. Anecdotal evidence suggests that superior reinnervation results are seen in genitoplasty compared to other peripheral nerve repair scenarios. Despite these observed differences, the quality of available literature is poor. METHODS The authors reviewed the body of English language literature regarding sensory outcomes following genitoplasty for gender confirmation. RESULTS The available body of literature discussing the basic science and clinical science aspects of sensory recovery following gender-confirming genitoplasty is small. Available data show that sensory recovery following vaginoplasty produces high rates of reported orgasmic ability, largely through the neoclitoris, and a neovagina with vibratory and pressure sensation similar to that of the native vagina. Phalloplasty sensory outcomes are variable, with the largest series reporting return of sensation in the neophallus that is slightly less than what is measured in control men. Erogenous sensation, including the ability to orgasm, is present in nearly all patients after several months. CONCLUSIONS Existing series indicate that genitoplasty patients experience faster and more complete recovery than any other peripheral nerve regeneration scenarios. However, there are many potential confounding factors in assessment and reporting, and more consistent and reproducible measure endpoints measures are needed. Further research is needed to better understand both the basic science and clinical science of peripheral nerve regeneration in genitoplasty, which may change fundamental aspects of current paradigms of peripheral nerve regeneration.
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Le Donne M, Jouan R, Bourlet J, Louvrier A, Ducret M, Sigaux N. Inferior alveolar nerve allogenic repair following mandibulectomy: A systematic review. J Stomatol Oral Maxillofac Surg 2021; 123:233-238. [PMID: 33933668 DOI: 10.1016/j.jormas.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Processed nerve allografts (PNA) are an alternative to nerve autografts to reconstruct the inferior alveolar nerve (IAN) when it is damaged. The purpose of this study was to report the results of IAN reconstruction using PNA in the context of aggressive benign mandibular pathology. MATERIAL AND METHOD A systematic literature review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement through the MEDLINE (Pubmed) and SCOPUS (Elsevier) databases. Studies concerning reconstructive surgeries of IAN by PNA, performed at the same time as the surgical resection of the benign pathologies of the mandible were included. The following data were analyzed: gender and patient age, cause of mandibular resection, graft dimensions, sensory recovery at least 6 months after surgery according to the MRC scale, and adverse events related to the intervention. RESULTS The initial search yielded 290 studies and 5 were included in the final review. A total of 33 patients underwent 36 IAN reconstructions; 14 patients were female (42.4%) and mean age was 30 years old. The mean length of graft used was 64.0 ± 9.1 mm. The most common pathology that led to nerve resection was ameloblastoma (52%). Among the reconstructions for which follow-up data were available, functional sensory recovery occurred in 92.9% of cases. CONCLUSION PNA are a reliable, safe, and effective alternative to nerve autografts for the rehabilitation of the IAN with 92.9% of functional recovery according to the reported literature, avoiding any comorbidity associated with the use of a donor site.
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Affiliation(s)
- Mélanie Le Donne
- Private Practitioner, 3 Rue du Dr François Broussais 17100 Saintes, France, Faculté d'Odontologie, Université de Lyon, Université Claude Bernard Lyon 1, 11 rue Guillaume Paradin, 69008 Lyon, France.
| | - Robin Jouan
- Clinical Doctor, Chirurgie Maxillo-faciale, Hôpital Nord-Ouest, Plateau d'Ouilly 69400 Gleizé Villefranche sur Saône, France
| | - Jérôme Bourlet
- Clinical Doctor, Hospices Civils de Lyon, Chirurgie Maxillo-faciale et Stomatologie, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France
| | - Aurélien Louvrier
- Clinical Doctor, Service de chirurgie Maxillo-faciale et Stomatologie, Centre Hospitalier Régional Universitaire Jean Minjoz, 3 boulevard Alexandre Fleming, 25000 Besançon, France
| | - Maxime Ducret
- Associate Professor, Hospices Civils de Lyon, PAM Odontologie, Lyon, France, Faculté d'Odontologie, Université de Lyon, Université Claude Bernard Lyon 1, 11 rue Guillaume Paradin 69008 Lyon, France; Faculty of Dentistry, McGill University, 2001 Avenue McGill College #500 Montreal QC H3A 1G1, Canada
| | - Nicolas Sigaux
- Clinical Doctor, Hospices Civils de Lyon, Chirurgie Maxillo-faciale et Plastique de la face, Hôpital Lyon Sud, 165 chemin du Grand Revoyet, 69310 Pierre-Bénite, France,; UFR de Médecine Lyon Sud, Université Claude Bernard Lyon 1, Université de Lyon, 165 Chemin du petit Revoyet, 69221 Oullins, France
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Kaleem A, Amailuk P, Hatoum H, Tursun R. The Trigeminal Nerve Injury. Oral Maxillofac Surg Clin North Am 2020; 32:675-687. [PMID: 32912777 DOI: 10.1016/j.coms.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Trigeminal nerve branches are never far from the operating field of the oral and maxillofacial surgeon. Increasingly the surgeon is required to provide accurate diagnosis and grading of trigeminal nerve injury, and surgical management by oral and maxillofacial surgeons will become common. Although trauma and ablative procedures for head and neck pathology can cause injuries, dentoalveolar surgical procedures remain an important cause of injury to the fifth cranial nerve, with the third division being the main branch affected. Oral and maxillofacial surgeons should be aware of strategies of avoiding iatrogenic injury, and know when referral and surgical management are appropriate.
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Affiliation(s)
- Arshad Kaleem
- Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Miami, Deering Medical Plaza, 9380 Southwest 150th Street, Suite 170, Miami, FL 33176, USA
| | - Paul Amailuk
- Department of oral and maxillofacial surgery, Gold Coast University Hospital, 1 hospital Boulevard, Queensland 4215, Australia
| | - Hisham Hatoum
- Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Miami, Deering Medical Plaza, 9380 Southwest 150th Street, Suite 170, Miami, FL 33176, USA
| | - Ramzey Tursun
- Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Miami, Deering Medical Plaza, 9380 Southwest 150th Street, Suite 170, Miami, FL 33176, USA.
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Kuffler DP, Foy C. Restoration of Neurological Function Following Peripheral Nerve Trauma. Int J Mol Sci 2020; 21:E1808. [PMID: 32155716 DOI: 10.3390/ijms21051808] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/25/2020] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Following peripheral nerve trauma that damages a length of the nerve, recovery of function is generally limited. This is because no material tested for bridging nerve gaps promotes good axon regeneration across the gap under conditions associated with common nerve traumas. While many materials have been tested, sensory nerve grafts remain the clinical “gold standard” technique. This is despite the significant limitations in the conditions under which they restore function. Thus, they induce reliable and good recovery only for patients < 25 years old, when gaps are <2 cm in length, and when repairs are performed <2–3 months post trauma. Repairs performed when these values are larger result in a precipitous decrease in neurological recovery. Further, when patients have more than one parameter larger than these values, there is normally no functional recovery. Clinically, there has been little progress in developing new techniques that increase the level of functional recovery following peripheral nerve injury. This paper examines the efficacies and limitations of sensory nerve grafts and various other techniques used to induce functional neurological recovery, and how these might be improved to induce more extensive functional recovery. It also discusses preliminary data from the clinical application of a novel technique that restores neurological function across long nerve gaps, when repairs are performed at long times post-trauma, and in older patients, even under all three of these conditions. Thus, it appears that function can be restored under conditions where sensory nerve grafts are not effective.
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Pagella P, Miran S, Neto E, Martin I, Lamghari M, Mitsiadis TA. Human dental pulp stem cells exhibit enhanced properties in comparison to human bone marrow stem cells on neurites outgrowth. FASEB J 2020; 34:5499-5511. [PMID: 32096581 DOI: 10.1096/fj.201902482r] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/22/2020] [Accepted: 02/12/2020] [Indexed: 12/17/2022]
Abstract
Mesenchymal stem cells (MSCs) have the capacity to self-renew and differentiate into specific cell types and are, therefore, key players during tissue repair and regeneration. The use of MSCs for the regeneration of tissues in vivo is increasingly being explored and already constitutes a promising alternative to existing clinical treatments. MSCs also exert paracrine and trophic functions, including the promotion of innervation that plays fundamental roles in regeneration and in restoration of the function of organs. Human bone marrow stem cells (hBMSCs) and human dental pulp stem cells (hDPSCs) have been used in studies that aimed at the repair and/or regeneration of bone or other tissues of the craniofacial complex. However, the capabilities of hBMSCs and hDPSCs to elicit the growth of specific axons in order to reestablish functional innervation of the healing tissues are not known. Here, we compared the neurotrophic effects of hDPSCs and hBMSCs on trigeminal and dorsal root ganglia neurons using microfluidic organs-on-chips devices. We found that hDPSCs express significantly higher levels of neurotrophins than hBMSCs and consequently neurons cocultured with hDPSCs develop longer axons in the microfluidic co-culture system when compared to neurons cocultured with hBMSCs. Moreover, hDPSCs elicited the formation of extensive axonal networks and established close contacts with neurons, a phenomenon not observed in presence of hBMSCs. Taken together, these findings indicate that hDPSCs constitute a superior option for restoring the functionality of damaged craniofacial tissues, as they are able to support and promote extensive trigeminal innervation.
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Affiliation(s)
- Pierfrancesco Pagella
- Orofacial Development and Regeneration, Institute of Oral Biology, Centre of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Shayee Miran
- Orofacial Development and Regeneration, Institute of Oral Biology, Centre of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Estrela Neto
- i3S, University of Porto, Porto, Portugal.,Institute of Biomedical Engineering (INEB), University of Porto, Porto, Portugal
| | - Ivan Martin
- Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Meriem Lamghari
- i3S, University of Porto, Porto, Portugal.,Institute of Biomedical Engineering (INEB), University of Porto, Porto, Portugal
| | - Thimios A Mitsiadis
- Orofacial Development and Regeneration, Institute of Oral Biology, Centre of Dental Medicine, University of Zurich, Zurich, Switzerland
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Ugradar S, Bonelli L, Rootman D. Facial numbness in the ophthalmology clinic. A portentous sign. Eye (Lond) 2020; 34:663-8. [PMID: 31471563 DOI: 10.1038/s41433-019-0565-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/25/2019] [Accepted: 07/16/2019] [Indexed: 11/08/2022] Open
Abstract
AIM To report a case series of 14 patients presenting with facial numbness primarily to the ophthalmology clinic. METHODS All patients presenting with facial numbness to the ophthalmology clinic at the University of California, Los Angeles, were reviewed for study entry between 1993 and the present. Patients with a history of trauma or surgery were excluded. RESULTS Fourteen patients (eight females and six males) presented to the ophthalmology clinic with numbness. Nine patients (64%) presented primarily with numbness. This symptom was associated with mortality (57%) and significant morbidity. The most common cause was neoplastic pathology (n = 10, 71%), with perineural spread from squamous cell carcinoma being the most common (five cases, 36%). The remaining cases were related to infection (n = 4, 29%). CONCLUSIONS Most of the patients presenting to our service with numbness eventually died due to their condition. Given the poor prognosis of the patients in our case series, numbness of the face may be a portentous sign and therefore warrants a thorough examination with close follow up.
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Taraquois R, Joly A, Sallot A, Kün Darbois JD, Laure B, Paré A. [Inferior alveolar nerve reconstruction after segmental resection of the mandible]. ACTA ACUST UNITED AC 2016; 117:438-441. [PMID: 27473928 DOI: 10.1016/j.revsto.2016.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The sacrifice of inferior alveolar nerve (IAN) is usual in case of resection of mandibular tumors and is responsible for disabling sensory disorders, drooling and lip incompetence. We report the case of a reconstruction of the IAN by means of an autologous nerve graft after segmental resection of the mandible. OBSERVATION A 27-year-old man presented with a recurrence of mandibular ameloblastoma. Treatment consisted in segmental mandibulectomy with resection of the IAN. Bone reconstruction was performed with a fibula free flap and IAN reconstruction was obtained by mean of a 7-cm nerve graft obtained from the greater auricular nerve (GAN). At the 6th postoperative month, the patient had recovered a normal sensitivity of his lower lip and chin. Latency of somatosensory evoked potentials was similar for both sides. DISCUSSION The repair of the IAN by nerve autograft is a simple procedure that allows for good sensitive rehabilitation. The use of the GAN is well suited from its anatomy and from the moderate ear sensory sequelae.
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Affiliation(s)
- R Taraquois
- Service de chirurgie maxillo-faciale et plastique de la face, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France; Service de plastique reconstructrice et esthétique, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France.
| | - A Joly
- Service de chirurgie maxillo-faciale et plastique de la face, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France
| | - A Sallot
- Service de plastique reconstructrice et esthétique, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France
| | - J-D Kün Darbois
- Service de chirurgie maxillo-faciale et plastique de la face, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France
| | - B Laure
- Service de chirurgie maxillo-faciale et plastique de la face, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France
| | - A Paré
- Service de chirurgie maxillo-faciale et plastique de la face, CHU Trousseau, avenue de la République, 37170 Chambray-lès-Tours, France
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Hergt AC, Beck-Broichsitter BE, Raethjen J, Käser N, Hülsmann M, Wiltfang J, Heine J, Becker ST. Nerve regeneration techniques respecting the special characteristics of the inferior alveolar nerve. J Craniomaxillofac Surg 2016; 44:1381-6. [PMID: 27435058 DOI: 10.1016/j.jcms.2016.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 05/21/2016] [Accepted: 06/27/2016] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The aim of this study was to examine the in situ regeneration of the inferior alveolar nerve (IAN) in its bony channel, using autologous tissue in combination with a recombinant human nerve growth factor (rhNGF). MATERIALS AND METHODS A total of 20 New Zealand rabbits were randomly divided into five groups. Following dissection of the IAN, the animals underwent reconstruction either with muscle tissue (groups 1 and 2) or with fat tissue (groups 3 and 4). In group 5 (control), the dissected nerve was resected and reconstructed by placement of the reversed autologous segment. After 2 and 4 weeks, 1 mL rhNGF was locally injected in groups 1 and 3. Nerve function was monitored by measuring the jaw-opening reflex using electromyography for a period of 24 weeks. RESULTS Regeneration of the nerve was achieved in all groups, but preoperative threshold values were not achieved. Comparing the experimental groups to the control, there was a significant difference in favor of the autologous nerve reconstruction. Differences between the experimental groups remained statistically not significant. CONCLUSION Regeneration of the IAN with autologous tissue is possible, but without achieving preoperative thresholds. Additional injection of a growth factor seems to improve the speed of regeneration for fat and muscle grafts.
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Seo K, Terumitsu M, Inada Y, Nakamura T, Shigeno K, Tanaka Y. Prognosis After Surgical Treatment of Trigeminal Neuropathy with a PGA-c Tube: Report of 10 Cases. Pain Med 2016; 17:2360-2368. [DOI: 10.1093/pm/pnw088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Shin Y, Roh BD, Kim Y, Kim T, Kim H. Accidental injury of the inferior alveolar nerve due to the extrusion of calcium hydroxide in endodontic treatment: a case report. Restor Dent Endod 2016; 41:63-7. [PMID: 26877992 PMCID: PMC4751209 DOI: 10.5395/rde.2016.41.1.63] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 11/24/2015] [Indexed: 11/28/2022] Open
Abstract
During clinical endodontic treatment, we often find radiopaque filling material beyond the root apex. Accidental extrusion of calcium hydroxide could cause the injury of inferior alveolar nerve, such as paresthesia or continuous inflammatory response. This case report presents the extrusion of calcium hydroxide and treatment procedures including surgical intervention. A 48 yr old female patient experienced Calcipex II extrusion in to the inferior alveolar canal on left mandibular area during endodontic treatment. After completion of endodontic treatment on left mandibular first molar, surgical intervention was planned under general anesthesia. After cortical bone osteotomy and debridement, neuroma resection and neurorrhaphy was performed, and prognosis was observed. But no improvement in sensory nerve was seen following surgical intervention after 20 mon. A clinician should be aware of extrusion of intracanal medicaments and the possibility of damage on inferior alveolar canal. Injectable type of calcium hydroxide should be applied with care for preventing nerve injury. The alternative delivery method such as lentulo spiral was suggested on the posterior mandibular molar.
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Affiliation(s)
- Yooseok Shin
- Department of Conservative Dentistry, Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Korea
| | - Byoung-Duck Roh
- Department of Conservative Dentistry, Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Korea
| | - Yemi Kim
- Department of Conservative Dentistry, Ewha Womans University, Seoul, Korea
| | - Taehyeon Kim
- Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea
| | - Hyungjun Kim
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University, Seoul, Korea
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Biglioli F, Allevi F, Lozza A. Surgical treatment of painful lesions of the inferior alveolar nerve. J Craniomaxillofac Surg 2015; 43:1541-5. [DOI: 10.1016/j.jcms.2015.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/18/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022] Open
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Affiliation(s)
- Shayan Abdollah Zadegan
- Tissue Repair Laboratory, Institute of Biochemistry and Biophysics (IBB), University of Tehran , Tehran , Iran ; Research Center for Neural Repair (RCNR), University of Tehran , Tehran , Iran
| | - Masoumeh Firouzi
- Tissue Repair Laboratory, Institute of Biochemistry and Biophysics (IBB), University of Tehran , Tehran , Iran ; Research Center for Neural Repair (RCNR), University of Tehran , Tehran , Iran
| | - Mohammad Hossein Nabian
- Research Center for Neural Repair (RCNR), University of Tehran , Tehran , Iran ; Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Leila Oryadi Zanjani
- Research Center for Neural Repair (RCNR), University of Tehran , Tehran , Iran ; Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Reza Shahryar Kamrani
- Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences , Tehran , Iran ; Joint Reconstruction Research Center, Tehran University of Medical Sciences , Tehran , Iran
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Kuffler DP. An assessment of current techniques for inducing axon regeneration and neurological recovery following peripheral nerve trauma. Prog Neurobiol 2014; 116:1-12. [DOI: 10.1016/j.pneurobio.2013.12.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 12/11/2013] [Accepted: 12/17/2013] [Indexed: 12/20/2022]
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Semere A, Morand B, Loury J, Vuillerme N, Bettega G. [Repair of a facial nerve substance loss by interposition of a collagen neurotube]. ANN CHIR PLAST ESTH 2014; 59:273-5. [PMID: 24698336 DOI: 10.1016/j.anplas.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
We are exposing the case of a 22 year-old patient presenting a wound of the right cheek, with a palsy of the right corner of the mouth. He has been sent to us 6 days after the trauma for secondary exploration. A section of the buccal branch of the right facial nerve with a 1cm gap has been brought out. We have bypassed the loss of substance with a collagen absorbable biological conduit. The 6-months clinical and electromyographic follow-up has shown a clear improvement of the function of the orbicularis oris, as well as its reinnervation by the buccal branch of the right facial nerve.
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Affiliation(s)
- A Semere
- Service de chirurgie de la main et des brûlés, hôpital Michallon, BP 217, 38043 Grenoble cedex 9, France.
| | - B Morand
- Service de chirurgie plastique maxillo-faciale, hôpital Michallon, BP 217, 38043 Grenoble cedex 9, France
| | - J Loury
- Clinique des Cèdres, 21, rue Albert-Londres, 38432 Echirolles, France
| | - N Vuillerme
- Laboratoire AGIM (AGeing Imaging, Modeling) Lab, faculté de médecine, Bât-Jean-Roget, 38706 La Tronche cedex, France
| | - G Bettega
- Service de chirurgie plastique maxillo-faciale, hôpital Michallon, BP 217, 38043 Grenoble cedex 9, France
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Sivolella S, Brunello G, Ferrarese N, Della Puppa A, D'Avella D, Bressan E, Zavan B. Nanostructured guidance for peripheral nerve injuries: a review with a perspective in the oral and maxillofacial area. Int J Mol Sci 2014; 15:3088-117. [PMID: 24562333 PMCID: PMC3958900 DOI: 10.3390/ijms15023088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/03/2014] [Accepted: 02/10/2014] [Indexed: 12/12/2022] Open
Abstract
Injury to peripheral nerves can occur as a result of various surgical procedures, including oral and maxillofacial surgery. In the case of nerve transaction, the gold standard treatment is the end-to-end reconnection of the two nerve stumps. When it cannot be performed, the actual strategies consist of the positioning of a nerve graft between the two stumps. Guided nerve regeneration using nano-structured scaffolds is a promising strategy to promote axon regeneration. Biodegradable electrospun conduits composed of aligned nanofibers is a new class of devices used to improve neurite extension and axon outgrowth. Self assembled peptide nanofibrous scaffolds (SAPNSs) demonstrated promising results in animal models for central nervous system injuries, and, more recently, for peripheral nerve injury. Aims of this work are (1) to review electrospun and self-assembled nanofibrous scaffolds use in vitro and in vivo for peripheral nerve regeneration; and (2) its application in peripheral nerve injuries treatment. The review focused on nanofibrous scaffolds with a diameter of less than approximately 250 nm. The conjugation in a nano scale of a natural bioactive factor with a resorbable synthetic or natural material may represent the best compromise providing both biological and mechanical cues for guided nerve regeneration. Injured peripheral nerves, such as trigeminal and facial, may benefit from these treatments.
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Affiliation(s)
- Stefano Sivolella
- Department of Neurosciences, Institute of Clinical Dentistry,University of Padova, Via Venezia, 90, 35129 Padova, Italy.
| | - Giulia Brunello
- Department of Neurosciences, Institute of Clinical Dentistry,University of Padova, Via Venezia, 90, 35129 Padova, Italy.
| | - Nadia Ferrarese
- Department of Neurosciences, Institute of Clinical Dentistry,University of Padova, Via Venezia, 90, 35129 Padova, Italy.
| | - Alessandro Della Puppa
- Department of Neurosciences, University of Padua, via Giustiniani, 5, 35128 Padua, Italy.
| | - Domenico D'Avella
- Department of Neurosciences, University of Padua, via Giustiniani, 5, 35128 Padua, Italy.
| | - Eriberto Bressan
- Department of Neurosciences, Institute of Clinical Dentistry,University of Padova, Via Venezia, 90, 35129 Padova, Italy.
| | - Barbara Zavan
- Department of Biomedical Sciences, University of Padova, Via G. Colombo 3, 35100 Padova, Italy.
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Hsieh JH, Lin WM, Chiang H, Chang LY, Wu CT, Pu CM, Wu JT, Hsieh ST. Patterns of target tissue reinnervation and trophic factor expression after nerve grafting. Plast Reconstr Surg 2013; 131:989-1000. [PMID: 23385987 DOI: 10.1097/PRS.0b013e3182870445] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reinnervation of target tissues determines functional outcomes after nerve grafting, which is important in traumatic injury caused by accidents or consequences resulting from surgical removal of tumors. Previous studies documented the influences of nerve repair mainly based on nerve morphometry but rarely compared the final outcomes according to target reinnervation patterns by nerve fibers of different categories. METHODS In a mouse model of nerve grafting, the authors analyzed the innervation indexes of different target tissues after transection-reimplantation on the sciatic nerve, which were defined as a parameter on the operated side normalized to that on the control side. RESULTS Muscle reinnervation appeared to be the best compared with skin reinnervation (p < 0.0001) and sweat gland reinnervation (p < 0.0001) at postoperative month 3. The sudomotor reinnervation was relatively higher than the cutaneous reinnervation (p = 0.014). The abundance of trophin transcripts for brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), and neurotrophin 3 (NT3) was higher in plantar muscles on the operated side than those on the control side. In contrast, transcripts of BDNF, GDNF, nerve growth factor, and NT3 were all similar in the footpad skin between the operated and control sides. CONCLUSIONS The results suggested that, compared with the skin, muscles achieved the best reinnervation after nerve grafting, which was related to higher expression of BDNF, GDNF, and NT3 in muscles than in the skin.
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Boffano P, Roccia F, Gallesio C. Lingual nerve deficit following mandibular third molar removal: review of the literature and medicolegal considerations. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:e10-e18. [PMID: 22669152 DOI: 10.1016/j.tripleo.2011.06.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 06/05/2011] [Accepted: 06/28/2011] [Indexed: 12/15/2022]
Abstract
The removal of mandibular third molars is probably the most frequently performed procedure in oral and maxillofacial surgery, and it is the most common surgical procedure associated with lingual nerve deficit. Lingual sensory impairment remains a clinical problem in oral and maxillofacial surgery and has serious medical and legal implications. In fact, damage to the lingual nerve is a common cause of litigation in dentistry. The purpose of this article was to review the literature about lingual nerve deficit following mandibular third molar removal and discuss the associated medicolegal aspects.
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Kuffler DP, Reyes O, Sosa IJ, Santiago-Figueroa J. Neurological recovery across a 12-cm-long ulnar nerve gap repaired 3.25 years post trauma: case report. Neurosurgery 2012; 69:E1321-6. [PMID: 21712738 DOI: 10.1227/neu.0b013e31822a9fd2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE The standard clinical technique for repairing peripheral nerve gaps is the use of autologous sensory nerve grafts. The present study tested whether a collagen tube filled with autologous platelet-rich fibrin could induce sensory and motor recovery across a 12-cm nerve gap repaired 3.25 years post trauma, and reduce or eliminate neuropathic pain. CLINICAL PRESENTATION Two years postrepair, good ring and small finger motor function had developed that could generate 1 kg of force, and topographically correct 2-point discrimination and sensitivity to vibration in the small and ring finger and proximal but not distal wrist had developed. The patient's excruciating neuropathic pain was reduced to tolerable, and he avoided the indicated extremity amputation. The 12-cm-long nerve gap was bridged with a collagen tube filled with autologous platelet-rich fibrin. CONCLUSION We demonstrate that a conduit filled with platelet-rich fibrin can induce limited, but appropriate, sensory and motor recovery across a 12-cm nerve gap repaired 3.25 years post trauma, without sacrificing a sensory nerve, can reduce existing excruciating neuropathic pain to tolerable, and allow avoidance of an indicated upper-extremity amputation. We believe the technique can be improved to induce more extensive and reliable neurological recovery.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, San Juan, Puerto Rico 00901, USA.
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Kim JH, Kim SM, Jung HJ, Kim MJ, Lee JH. Effective end-to-end repair of inferior alveolar nerve defect by using nerve sliding technique. ACTA ACUST UNITED AC 2011; 112:e28-30. [DOI: 10.1016/j.tripleo.2011.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 03/24/2011] [Accepted: 03/31/2011] [Indexed: 11/28/2022]
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Curtis NJ, Owen E, Walker DM, Zoellner H. Comparison of microsuture, interpositional nerve graft, and laser solder weld repair of the rat inferior alveolar nerve. J Oral Maxillofac Surg 2011; 69:e246-55. [PMID: 21605793 DOI: 10.1016/j.joms.2011.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 12/11/2010] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Intraosseous repair of nerves involves difficulty of access and there is concern that bone healing may interfere with repair outcomes. The present report describes the effect of 3 separate repair techniques on recovery from section of the rat intraosseous inferior alveolar nerve, with reference to the mental nerve distal and the trigeminal ganglion proximal to the nerve section. MATERIALS AND METHODS Unilateral exposure of the inferior alveolar nerves of 28 rats was achieved through bone windows. Nerves were sectioned and rats were assigned to 1 of 4 groups (n = 7): untreated controls, microsuture repair, interpositional nerve grafts from the femoral nerve, or laser solder weld repair. Animals were sacrificed 1 year after surgery for histologic evaluation of the mental nerve, inferior alveolar nerve, and trigeminal ganglion compared with unoperated contralateral nerves. RESULTS Compared with the unoperated contralateral nerves, nerve section substantially decreased mental nerve fiber number, mental nerve myelination, mental nerve fiber diameter, inferior alveolar nerve vascularity, trigeminal neuron number, and trigeminal neuron horseradish peroxidase tracer uptake and increased trigeminal ganglion degenerate neurons (P < .001). All 3 forms of repair substantially decreased these effects (P < .05). Interpositional nerve graft was least effective (P < .05). Nonetheless, mental nerve fiber diameter was significantly decreased compared with unsectioned nerves after microsuture and laser solder weld repair (P < .05). CONCLUSIONS Intraosseous repair of the inferior alveolar nerve decreases peripheral and central signs of degeneration. Clinical hyperesthesia after repair may reflect a predominance of small fibers after recovery.
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Affiliation(s)
- Nigel J Curtis
- Microresearch Foundation of Australia and Microsurgery Institute, North Sydney, NSW, Australia
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Juodzbalys G, Wang HL, Sabalys G. Injury of the Inferior Alveolar Nerve during Implant Placement: a Literature Review. J Oral Maxillofac Res 2011; 2:e1. [PMID: 24421983 PMCID: PMC3886063 DOI: 10.5037/jomr.2011.2101] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 01/10/2011] [Indexed: 12/25/2022]
Abstract
Objectives The purpose of present article was to review aetiological factors,
mechanism, clinical symptoms, and diagnostic methods as well as to
create treatment guidelines for the management of inferior alveolar
nerve injury during dental implant placement. Material and Methods Literature was selected through a search of PubMed, Embase and Cochrane
electronic databases. The keywords used for search were inferior
alveolar nerve injury, inferior alveolar nerve injuries, inferior
alveolar nerve injury implant, inferior alveolar nerve damage, inferior
alveolar nerve paresthesia and inferior alveolar nerve repair. The
search was restricted to English language articles, published from 1972
to November 2010. Additionally, a manual search in the major anatomy,
dental implant, periodontal and oral surgery journals and books were
performed. The publications there selected by including clinical, human
anatomy and physiology studies. Results In total 136 literature sources were obtained and reviewed. Aetiological
factors of inferior alveolar nerve injury, risk factors, mechanism,
clinical sensory nerve examination methods, clinical symptoms and
treatment were discussed. Guidelines were created to illustrate the
methods used to prevent and manage inferior alveolar nerve injury before
or after dental implant placement. Conclusions The damage of inferior alveolar nerve during the dental implant
placement can be a serious complication. Clinician should recognise and
exclude aetiological factors leading to nerve injury. Proper presurgery
planning, timely diagnosis and treatment are the key to avoid nerve
sensory disturbances management.
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Affiliation(s)
- Gintaras Juodzbalys
- Department of Oral and Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas Lithuania
| | - Hom-Lay Wang
- Department of Oral and Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas Lithuania
| | - Gintautas Sabalys
- Department of Oral and Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas Lithuania
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