International Journal of Applied Dental Sciences 2017; 3(3): 08-19 

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2017; 3(3): 08-19 Nerve injuries – A review
© 2017 IJADS
www.oraljournal.com
Received: 03-05-2017 Dr. Rahul VC Tiwari, Dr. Mayank Jangid, Dr. Kukutla Padmaja Rani,
Accepted: 04-06-2017
Dr. Pranoti Hiralkar, Dr. Vijay Kumar Thumpala and Dr. Hena Dixit
Dr. Rahul VC Tiwari
Post Graduate Student, Department
of Oral and Maxillofacial Surgery, Abstract
Sibar Institute of Dental Sciences, Surgeons like to prevent nerve injuries on limit them to the mildest type; however, this is something that
Takkellapadu, Guntur, NTRUHS, is often beyond the control of the health care professional. If a more damaging injury is encountered
Vijayawada, Andhra Pradesh, India preventing the degeneration of the distal segment of the nerve is undesirable because this developmental
Dr. Mayank Jangid
like environment allows peripheral nerve regeneration to take place at its best inherent abilities. The goal
Post Graduate Student, Department in the early management of nerve injuries is to decide as soon as possible which injuries will profit from
of Oral and Maxillofacial Surgery, early repair and which should be followed.
Vyas Dental College and Hospital,
Jodhpur – 342005, RUHS,
Rajasthan, India
Keywords: Nerve anatomy, Nerve injury, Management of nerve injury

Dr. Kukutla Padmaja Rani Introduction

Post Graduate Student, Department
of Oral and Maxillofacial Surgery, The peripheral sensory innervation of the orofacial region may be injured by oral and
Sibar Institute of Dental Sciences, maxillofacial surgical and general dental procedures (eg: local anesthetic injections, 3rd molar
Takkellapadu, Gnutur, NTRUHS, extractions, mandibular osteotomies, dental implants, endodontic procedures, and
Vijayawada, Andhra Pradesh, India
preprosthetic surgery), trauma (eg: facial fractures) or secondary to pathologic destruction and
Dr. Pranoti Hiralkar treatment (eg: oral squamous cell carcinoma, resection). A goal for surgeons who manage
Post Graduate Student, Department
of Public Health Dentistry, Sibar
nerve – injured patients should be to develop methodology that enhances one or more of the
Institute of Dental Sciences, processes that allow a peripheral nerve to regrow and function again.
Takkellapadu, Gnutur, NTRUHS,
Vijayawada, Andhra Pradesh, India
Anatomy of Nerve
Dr. Vijay Kumar Thumpala Nerve trunk is composed of 4 connective tissue sheaths. Mesoneurium – is a sheath analogous
Post Graduate Student, Department to the Mesentery of the intestine which suspends the nerve trunk with in the soft tissue.
of Oral and Maxillofacial Surgery,
Sibar Institute of Dental Sciences, Epineurium – is the loose connective tissue sheath that defines the nerve. Trunk and protects
Takkellapadu, Gnutur, NTRUHS, against mechanical stress. Epineurium can occupy from 22 – 88% of the cross sectional
Vijayawada, Andhra Pradesh, India diameter of nerves with greater cross – sect diameter are more capable of withstanding
Dr. Hena Dixit compressive forces than tensile forces. Epineurium has an epifascicular layer, which surrounds
Bachelor of Dental Surgery, Rungta the entire nerve trunk, and lies superficial to the fascicles, and interfascicular layer, which
Institute of Dental Sciences, Bhilai,
Ayush University, Raipur, Post
occupies the space among the fascicles. The vasa nervorum, longitudinal blood vessels course
Graduate Diploma in Health Care and through the epineurium and give off branches that penetrate the perineurium to connect with
Hospital Management, Disha College, the endoneurial capillaries. Perineurium – Fascicles are delineated by the perineurium, which
Raipur, India
surrounds the axons and endoneurial sheaths. It is a continuation of the pia-arachnoid mater of
CNS. Composed of two layers. An outer layer of dense connective tissue and an inner cellular
layer made of a multilayered continuous sheet of flat squamous cells. Its functions are active
transport of certain molecules, diffusion barrier, maintaining positive pressure inside the
fascicle, providing structural support for the enclosed neural tissues, if the perineurium is
breached, the intrafascicular million is altered and conduction disturbances may result, an
intra-fascicular hemorrhage or edema results in an increased intra fascicular pressure that can
alter axonal conduction. Three fascicular pattern have been described: Monofascicular pattern:
is composed of one large fascicle surrounded by concentric layers of perineurium and
epifascicular epineurium. The facial nerve at the stylomastoid foramen has a monofascicular
Correspondence pattern or digofascicular pattern with only a few fascicles [1]. Oligofascicular pattern: is
Dr. Rahul VC Tiwari
Post Graduate Student, Department characterized by 2 to 10 rather large fascicles, each surrounded by perinueurium and all held
of Oral and Maxillofacial Surgery, together by epifascicular and interfascicular epineurium. Polyfascicular pattern: consists of
Sibar Institute of Dental Sciences,
Takkellapadu, Guntur, NTRUHS,
more than 10 fascicles of different sizes but with a prevalence of small fascicles. Both the IAN
Vijayawada, Andhra Pradesh, India and lingual nerves have polyfascicular patterns. The polyfascicular pattern has a large amount
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of nonfascicular tissue, which increases likelihood of occurred, the neuron return to normal size and electrical
misalignment of the fascicles during coaptation and epineurial activity. Proximal nerve trunk: 1hr after laceration of a nerve
fibrosis following injury. Endoneurium – Individual nerve there is marked swelling proximally as far as 1 cm. The cross-
fibers and their Schwann cells are surrounded by the sectional also may increase the three times normal and
endoneurium, composed of an external layer of collagen swelling persists for 1 week or more before slowly subsiding.
fibers and endoneurial fibroblasts and an internal layer of By the 7th day there is vigorous sprouting of axons. Each axon
basal lamina and endoneurial capillaries. Nerve fiber is the may have as many as 50 collateral sprouts. It is not until the
functional component of the peripheral nerve. It is composed 28th day that axons cross the point of injury and the forty-
of axon; Schwann cell and myelin sheath in myelinated nerve second day before a sizable no. of axons occupy the distal
fibers. Axon: is an extension of a neuron and can be segment [4]. Site of injury: Within hours of injury there is a
characterized by morphology, conduction velocity and proliferation of macrophages, perineurial fibroblasts,
function. A-alpha fibers are the largest myelinated fibers and Schwann cells and epineurial fibroblasts. By the 7th day the
range in diameter from 7-16 m conduction velocity – 70-120 Schwann cell is clearly the most active cell and assumes a
m/sec. A-beta fibers are next largest myelinated axons. The phagocytic function of debridement. The Schwann cell
diameter  6-8 m. its conduction velocity  30-70 m/sec. response is proportional to the security of the injury. Distal
Sensibility of touch is attributed to these axons. A- Delta nerve trunk: It undergoes Wallerian degeneration in
fibers are smallest of the myelinated fibers. Diameter is 205- preparation for the arrival of sprouting axons. Wallerian
4m. Conduction velocity is 0.5-2m/sec [2]. It transmit stimuli degeneration is initiated because all distal neural elements die.
encoded for slow or second pain, temperature and efferent By 7th post injury day the majority of neural elements break
sympathetic fibers. Schwann cell is essential for axon down, facilitated by digestive enzymes present in the axons.
survival, whether myelinated or unmyelinated. It surrounds Majority of cellular debris has been phagocytosed by
several unmyelinated axon to form well-defined units that are Schwann cells by 21st day. At 42 days debridement is
interspersed among myelinated fibers is a fascicle. In complete and parts of the fascicular anatomy persist.
myelinated nerve fibers multiple layers of the cell membrane Endoneurial tubules either shrink or collapse. Tubules (bands
of the Schwann axon to form a myelin sheath over a definable of Bungner) composed of Schwann cells surrounded by
segment of axon, the inter node. collages guide axons toward the distal nerve trunk. Initially
several axons may occupy a single distal tubule. But axonal
Terminology numbers decrease during regeneration. With the arrival of
Allodynia: Pain due to stimulus that does not normally new axons, Schwann cell again increase metabolic activity
provoke pain. Analgesia: Absence of pain in response to new myelin is layered around the axons by Schwann cells.
stimulation that would normally be painful. Anesthesia: New myelination is never as good as the original and the axon
Absence of any sensation in response to stimulation that diameters are smaller. The endoneurial tubes are smaller in
would normally be painful 02 nonpainful. Anesthesia diameter and the nodes of Ranvier shorter, resulting in slower
dolorosa: Pain in an area or region that is anesthetic. conduction velocities. The rate of axon regeneration varies
Causalgia: Burning pain, allodynia and hyperpathia after during the process of repair. There is an initial delay until the
partial injury of a nerve. Dysesthesia: An unpleasant (usually axon has crossed the site of injury. The rate of axon
painful) abnormal sensation, whether spontaneous or evoked. advancement increases to 1 to 3 per day, followed by another
Special cases of dyesthesia include hyperalgesia and slowing and delay as axons form new connections with
allodynia. Hyperesthesia: Increased sensitivity to stimulation, sensory organs [5].
excluding the special senses. Hyperalgesia: A painful
syndrome, characterized by increased reaction to a stimulus, Etiology of Nerve Injuries
especially a repetitive stimulus, as well as an increased Meyer listed the procedures most commonly associated with
threshold. Hypoesthesia: Decreased sensitivity to stimulation, trigeminal nerve injuries seen the most common procedure
excluding the special senses. Hypoalgesia: Diminished pain in associated with a trigeminal nerve injury was the removal of
response to a normally painful stimulus. Paresthesia: An impacted teeth followed by osteotomies, fractures and dental
abnormal sensation, whether spontaneous or evoked. It should implants, alveolar ridge augmentation with hydroxyapatite,
be used to describe an abnormal sensation that is not root canal therapy, tumor resection and genioplasty other
unpleasant and dysthesia an abnormal sensation considered to miscellaneous causes of trigeminal nerve injuries included
be unpleasant [3]. salivary gland excision, vestibuloplasty. Biopsies, gunshot
wounds, and bony cyst excision. Some of the etiologic factors
Nerve Injury such as trauma and tumor surgery are unpreventable. A nerve
Degeneration and Regeneration: When nerve is injured may be injured by open wound such as cuts, gunshots. Closed
there are responses distal to the injury, at the site of injury, injury as by external pressure, compression, stretch, fracture
proximal to the site of injury and within the CNS. Neuron and chronic irritation. Effect of nerve injury Depends on the
undergoes hypertrophic changes that begin on the third or 4th type of nerve, pure motor, pure sensory or mixed. Motor
day following injury to the axon and peak between the 10th effect, Paralysis of muscles, Atrophy of muscles and
and 20th day. Total RNA content of the cell increases as the replacement of muscle fibers by fibro fatty tissue, Due to free
cell increases in size RNA migrates to the outer edges of the over play of intact antagonist muscles. A change in position
cell and break up in to smaller particles. Neuron is beginning of joint or attitude results. Reaction of degeneration: this
an anabolic proteosynthetic state that is maintained as large as means certain electrical changes in muscles supplied by
there are regenerative efforts – up to many years. injured nerve. Normally a muscle responds to faradic and
Chromatolytic hypertrophic changes are more pronounced in galvanic current and cathodal closing contraction (KCC) is
more proximal injuries. Sometimes the neuron cannot meet more than anodal closing contraction (ACC). After injury
these metabolic demands and cell death occurs. After muscles responds only to galvanic current for about a week
regeneration is complete and conduction maturation has and after 10 days there is no response to either galvanic or
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faradic current. And there is polar reversal i.e. ACC is more Sunderland classification is the same as the neuropraxia in the
than KCC. Fibrillation: In partially injured nerves or during Seddon classification. Axonal conduction is temporarily
recovery state, the affected muscle exhibits irregular twitching blocked and all the tissue components of the nerve are intact.
contractions known as fibrillations. Sensory effects includes Axonal conduction blockade may be the result of ischemia or
anesthesia where there is loss of pain, touch, pressure & temp. mechanical demyelination. There are 3 types of first-degree
Sensation, Pain – due to the partial injury – also known as nerve injury based in the proposed mechanism of conduction
causalgia, Pseudomotor effects, Hyper-hydrosis – increased block. First degree, Type I injury results from nerve trunk
sweating due to partial injury, Anhydrosis – absence of manipulation. Mild traction or mild compression such as
sweating and complete dryness due to total nerve injury. occurs during sagittal split osteotomy, Inferior Alveolar nerve
Vasomotor effect there is vasodilatation in the denervated repositioning or Lingual nerve manipulation during
skin due to paralysis of vasoconstrictor fibers so that skin is sialadenectomy of the sublingual or submandibular gland. The
red and warm. There is loss of both superficial and deep mechanism of the conduction block is presumed to be anoxia
reflexes if the injures nerve is a part of reflex arc. Nutritional from interruption of the segmental or epineural blood vessels,
changes like skin become smooth and inelastic loses pits and but there is no axonal degeneration or demyelination. Normal
wrinkles, decreased resistance to trauma leading to indolent sensation or function returns within several hours (less than 2
ulcers, loss of subcutaneous tissues, loss of hair, and hours) following the restoration of circulation. A first degree,
distortion of nails. The squeal is contractures, ankylosis of type II injury results from moderate manipulation, traction or
joint, decalcification of bones [6]. compression of a nerve. Intrafascicular edema from trauma of
sufficient magnitude to injure the endoneurial capillaries
Classification of Nerve Injuries results in a conduction block. Normal sensation or function
The appropriate and logical management of nerve injuries is returns within 1 –2 days following the resolution of
based on the accurate description and classification of the intrafascicular edema which generally occurs within 1 week
nerve injury. A variety of classification schemes have been following nerve injury. First degree, type III nerve injuries
proposed, the most common of these being the Seddon and results from severe nerve manipulation, traction or
Sunderland Classification. compression. Pressure on the nerves causes segmental
demyelination or mechanical disruption of the myelin sheaths.
Seddon Classification: Described 3 types of nerve injuries – Sensory and functional recovery is complete within 1 –2
based upon the severity of tissue injury, prognosis for months. The psychophysical response to this type of injury is
recovery and the time frame for recovery. Neuropraxia, paresthesia. Microconstructive surgery is not indicated for
Axonotmesis and Neurotmesis. Neuropraxia is a common first-degree nerve injuries unless there is a foreign body
block resulting from a mild insult to the nerve trunk. There is irritant. The second, third and fourth degree injuries of
no axonal degeneration. Sensory recovery is complete and Sunderland overlap with Seddon’s axonotmesis. The afferent
occurs in a matter of hours to several days. There is or efferent fibers (axons) damaged the undergo degeneration.
physiological paralysis of conduction and the nerve fibers The remaining tissue components of the nerve trunk,
otherwise intact. The cause of injury is usually a stretch or endoneurium, perineurium and epineurium remain intact. The
distortion – there may be segmental demyelination. The signs and symptoms usually associated with second-degree
magnitude of sensory deficit is usually mild and consists of a injuries include a generalized paresthesia with a localized area
paresthesia with some level of stimulus detection but poor of anesthesia. Surgical intervention is not necessary unless
discrimination and disturbed stimulus interpretation. there is a foreign body irritant [8].
Axonotmesis is a more severe injury than neuropraxia. In third degree injury the intrafascicular tissue components,
Afferent fibers undergo degeneration but the nerve trunk is the axons and endoneurium are damaged. Generally there is
grossly intact with variable degrees of tissue injury. There is some degree of intrafascicular fibrosis blocking the path of
rupture of nerve fibers in an intact sheath. The cause of such degenerating axons. This results in fair to poor sensory
as injury is an abnormal stress such as in fracture, traction recovery, with some degree of persistent paresthsia,
injuries, contusion of nerve with extensive hemorrhage into synhestheisa and increased two-point discrimination. The
its sheath and finally compression by tourniquets, splints etc incidence of neuroma in continuity is low because the
or by scar tissues. Sensory recovery is good but incomplete. perineurium and epineurium remain intact. The severity of the
The time course for sensory recovery is dependent on the rate sensory disturbance is directly related to the severity of the
of axonal regeneration; it is usually several months. The mechanical insult. The signs and symptoms can range from
sensory deficit is usually a severe paresthesia. The incidence paresthesia to dysthesia to anesthesia or any combination.
of neuropathic regeneration is very low, but a neuroma in These injuries must be monitored carefully, and surgical
continuity may rarely develop. Neurotmesis is a severance of intervention must be dictated by the nature of the sensory
the nerve and is the most severe injury in the classification. disturbance the recovery pattern, the presence of foreign body
There is partial or complete division of nerve fibers and irritant and suspected severity of the injury. In fourth degree
sheath caused by penetrating wounds. Sensory recovery is not injury fascicular disruption is the characteristics of this injury,
to be expected when the nerve courses through soft tissue. the perineurium, endoneurium and axons are all damaged.
Nerves that travel within a canal may exhibit some degree of The incidence of enuropathic sensory impairment is high
sensory recovery because of the guiding influence of the because of extensive internal fibrosis and only the epineurium
canal. The incidence of neropathic regeneration is high with remains intact. The prognosis for sensory recovery is poor.
this type of nerve injury. The sensory deficit of neurotemesis Sequelae of IV degree injury include anesthesia, dysesthesia,
is either an anesthesia or a dysesthesia [7]. synesthesia and severe paresthesia. Generally requires
surgical intervention to upgrade the injury and improve the
Sunderland Classification: The Sunderland classification is prognosis for favorable sensory recovery and to minimize the
based on the degree of tissue injury, there is considerable potential for neuropathic recovery. Sunderland’s fifth degree
overlap with the seddon classification. First-degree injury nerve injury is characterized by transection or rupture of the
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entire nerve trunk. This results in loss of nerve conduction at index of suspicion for severe nerve injury and poor prognosis
the level of the injury and within the distal nerve segment. of spontaneous sensory recovery (Crush injury of a nerve
Intraosseous fifth degree injury may undergo spontaneous located within either soft tissue or bony canal) presence of a
recovery of some degree of sensibility of this canal is intact. foreign body irritant with a poor or uncertain prognosis for
Soft tissue of fifth degree nerve injuries have poor prognosis spontaneous regeneration and sensory recovery (endosseous
for recovery and require surgical adaptation and coaptation. implant compressing the inf. Alveolar nerve). Paresthesia is
The prognosis depends on the nature of the injury, as well as an alteration in sensibility in which there is abnormal or
on local and general factors. The sixth degree injury pattern occasionally normal stimulus detection and stimulus
was added by Macjinnon and Dellon, to describe the perception that may be perceived as unpleasant but is not
combination of Sunderlands’ 5 degrees of injury. Within the painful. Stimulus detection may be normal, increased, or
same nerve trunk, some fascicles may exhibit normal function decreased and may affect wither mechanoreception or
and others will have various degree of nerve injury. [First nociception. Decreased touch and pressure stimuli detection is
through fifth degree injuries]. This injury pattern presents the called hypoesthesia, whereas increased perception of these
surgeon with the greatest challenge. The first, second and stimuli is called hyperesthesia. Decreased nociceptive stimuli
third degree nerve injuries will undergo spontaneous recovery detection is called – hypoalgesia. Increased perception is
superior to that provided by surgical neurography or grafting, called – hyperalgesia. Patient may additionally complaint of a
whereas the fourth and fifth degree nerve injuries require constant abnormal background perception, which they
surgical reconstruction [9]. describe as numb, tingling, itching, swollen, fat tight, heavy,
drawing and son on. These abnormalities of stimulus
Physiologic Conduction Block -Type “A” conduction block. detection and perception may be the result of conduction
The pathophysiologic basis for a type “A” conduction block is disturbances. Ischemia and alterations in protein transport
intraneural circulatory arrest or metabolic (ionic) block with occur, along the axon to the peripheral receptor, and not
no nerve fiber pathology. This conduction block is necessarily from disruption of axons. Difficulty in quickly
immediately reversible. This type of injuries best managed by and accurately localizing the point of stimulus of application
therapies that improve or restore circulation to the nerve trunk is called synesthesia. Synesthesia is probably the result of
such as sympathetic blockade, decompression or the use of misdirection of the axons during the process of degeneration
agents to decrease edema or reverse vasospasm. Intraneural and is a common finding following neurography. Protopathia
edema resulting in increased endoneural fluid pressure or is the inability to distinguish or differentiate between two
metabolic block with little or no nerve fiber pathology is the distinctly different stimuli, such as sharp and dull. Distal
basis for type “B” conduction block. This type of conduction anatomy is not a concern with paresthesia therefore no
block is reversible within days or week. Therapies to decrease urgency for surgical exploration and repair that there is with
edema and promote venous drainage are most appropriate in anesthesia. If there is a foreign body irritation causing
managing the type “B” conduction block [10]. paresthesia surgical intervention is indicated to remove the
foreign body.
Symptomatic Classification: Patients with sensory Dyesethesia is the alteration in sensibility in which there is
disturbances following nerve injury present with subjective abnormal stimulus detection and stimulus perception may be
complaints of numbness, which can be broadly classified, into perceived as unpleasant and painful. Dysesthesia shares all
anesthesia, paresthesia or dysesthesia. A thorough clinical the features of a paresthesia but has the additional features of
examination is necessary to describe and classify the sensory pain, which may be spontaneous, or triggered. Allodynia is a
disturbance resulting from nerve injury. First it is necessary to specific type of dysesthesia characterized by a sharp, first pain
understand the components of sensibility. Sensibility id the perception elicited by a light touch stimulus. Hyperpathia is
sum of stimulus detection, stimulus localization and stimulus another type of dysesthesia characterized by a dull, second
interpretation or perception. Stimulus detection is simply the pain elicited by a pressure stimulus. The pain of hyperpathia
ability to determine whether or not something is contacting lingers or has an after make that persists even after the
the skin or mucosa. The ability to accurately and precisely pressure stimulus is removed. Alodynia and Hyperpathia are
locate the point or area of stimulus contact is stimulus signs associated with neuromas, entrapment, compression and
localization. The ability to describe the stimulus, such as hot, sympathetically maintained pain. Initially dysesthesia must be
pricking, pressure, tickles and so on stimulus interpretation or managed non-surgically with supportive therapies to prevent
perception. Some examples of abnormal stimulus perceptions or minimize sensitization of wide dynamic range neurons that
include pulling, swollen, tight and tingling. Anesthesia is the result in central mediated pain or sympathetically mediated
complete lack of any stimulus detection and stimulus pain. If the mechanism of pain is determined to be due to a
reception, including mechanoreceptive and nociceptive peripheral neuropathy such as neuroma, entrapment or
stimuli – this is usually associated with a severe injury of the compression urgent surgical intervention is indicated to
nerve interrupting the integrity of the axons. Sensory recovery upgrade the nerve injury and convert dysesthesia to a
following anesthesia is slow and unpredictable. The timing of parasthesia with an improved prognosis for sensory recovery
[11]
the surgical intervention must be balanced against the .
potential for distal nerve trunk atrophy if the endoneural tubes
are not invaded by regenerating axon in a timely pattern. Anatomic Classification: Nerve injuries can be classified
Depending on the mechanism and circumstances of injury, anatomically as intraosseous and soft tissue. This distinction
early surgery may be indicated. Acute or early repair is is important because the management and prognosis for one
indicated for observed transection injuries of nerves located differ from the other.
within soft tissue, observed transection injuries of nerve
located within a bony canal when the canal has been disrupted Intraosseous Nerve Injury: Osseous canals provide
(Eg. Laceration of inf. alveolar nerve during sagital split protection from mechanical trauma unless the integrity of the
osteotomy). Anesthesia that persists for 3 months with a high canal is breached. The closed space of the osseous canal
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predisposes the enclosed nerve trunk to compartment There are two types of eccentric neuromas lateral exophytic
syndrome, which starts a cascade of events in the acute phase: and stellate neuromas of the inferior alveolar nerve. The
compression increased vascular permeability, edema, lateral exophytic neuroma is an outgrowth of axons and
increased endoneurial fluid pressure, ischemia and nerve fiber collagen, forming a terminal knob-like structure on an
dysfunction. The chronic effect of compression are fibreblast otherwise intact nerve. Only a few superficial fascicles are
invasion, scarring, fiber deformation – degeneration and nerve disrupted because of an incomplete transection of the nerve or
fiber dysfunction. Generally no acute surgical intervention is a poor coaptation of the distal and proximal nerve stumps.
necessary for mechanical injuries if the canal remains intact There is a recognizable breach of the epineurium at the site of
and if the nerve is not compressed by a foreign body or edema the lateral exophytic neuroma. The stellate neuroma has two
within the canal. Foreign bodies such as implants, tooth roots or more branches at the site of injury ending in adjacent soft
or displaced bony fragments must be removed acutely to tissue or mucosa. This type of neuroma has been identified
alleviate compression and prevent an unfavorable cascade of with the inferior alveolar nerve in the third molar area. These
events results from compression. Chemical injuries are unique collateral branches penetrate the lingual or buccal cortex and
and generally require acute surgical intervention to remove or end in the adjacent soft tissue. In contrast to the lateral
neutralize the agent followed by delayed micro reconstructive exophytic neuroma, the epineurium is intact and the branches
nerve surgery as indicated by progressive assessment of terminate in soft tissue. Stump neuromas are managed by
sensory recovery. The environment of a nerve has a bearing excision and preparation of the nerve ends, which are trimmed
on the suceptibility to injury prognosis for recovery and until a definite fascicular pattern can be identified and axonal
timing of surgical intervention osseous canal provide mushrooming is observed at the proximal stump. A direct
protection from mechanical trauma unless the integrity of the neurorrhaphy or graft is performed as indicated. The neuroma
canal is breached, conversely closed space of the osseous in-continuity is most difficult to manage surgically. The
canal predisposes the enclosed nerve trunk to compartment clinical appearance of the neuroma in-continuity is usually an
syndrome, which starts as cascade of events in the acute enlargement or bulging of the nerve with a relatively normal
phase, compression, increased vascular permeability edema or slightly enlarged proximal trunk diameter and reduced
and nerve fibre dysfunction the chronic effects of distal trunk diameter. The problem is to determine whether
compression are fibroblast invasion, scoring fibre deformation the sensory deficit is due to epineural fibrosis or fascicular
degeneration and nerve fibre dysfunction [12]. disruption, or both. The first step is to perform an
epifascicular epineurotomy and palpate the nerve to determine
Soft Tissue Nerve Injury: Nerves located within soft tissue whether there is interfascicualr scarring. If there is, an
are not afforded the protection from mechanical trauma that epifascicular epineurectomy and interfascicular
are intraossesous counterpart are within guiding influence of epineurectomy are performed. The nerve is again palpated to
an osseous canal, lacerations and transactions of nerve located determine whether there is intrafascicular scarring. If there is,
within soft tissue are more likely to form neuromas (either the scarred segment is excised and the nerve ends prepared for
symptomatic or asymptomatic) and are less likely to undergo neurorrhaphy or graft reconstruction. If the instrumentation is
spontaneous regeneration because of the formation of the scar available, evoked action potentials can be recorded
tissue between the injured ends. The lingual nerve because of intraoperatively across the neuroma or site of injury to
tissue close proximity to the lingual cortex of the mandible determine whether or not there is axonal continuity. This is a
seems to be very susceptible to entrapment injury that prevent great help in deciding whether or not to excise the damaged
guiding of the nerve [11]. segment. Generally, if the sensory deficit is that of
paresthesia, neurolysis is sufficient. Excision and
Histopathology Classification: Neuromas are characterized neurorrhaphy or graft reconstruction are generally indicated
by disorganized microsprouting and formation of a for anesthesias and dysesthesias. FIBROSIS: There are
disorganized mass of collagen and randomly oriented small various degrees of reactive fibrosis that occur following
neural fascicles. Peripheral neuromas can be classified as trauma to a nerve. These have been classified by Millesi.
amputation or stump, central, and eccentric. The amputation Type a fibrosis involves the epifascicular epineurium and is
or stump neuroma is a knobby, disorganized mass of axons associated with a good prognosis for recovery. Type B
and collagen associated with the proximal nerve stump and fibrosis involves the interfascicular epineurium. The
completely separated from the distal nerve stump. This type prognosis is guarded and depends on the original damage.
of neuroma is the result of a Sunderland fifth-degree injury. Internal neurolysis is indicated for the surgical management
The cental or neuroma in continuity is a fusiform expansion of type A and type B fibrosis. Type C fibrosis extends into the
or fibrotic narrowing of the nerve with variable degrees of endoneurium and has a poor prognosis. Type C fibrosis
fasciculoar disruption and disorganization. There is no breach requires excision of the scarred segment and neurorrhaphy or
of the epineurium. This type of neuroma is the result of a graft reconstruction. Types A, B, and C fibrosis can be used
Sunderland fourth-degree injury or fifth-degree injury in as modifies with the Sunderland classification: IA and IB, IIA
which continuity between the proximal and distal stumps was and IIB, IIIA, IIIB, and IIIC. Type N fibrosis is a Sunderland
re-established. The lateral entrapment neuroma of the lingual class IV injury in which epineural connective tissue maintains
nerve is a specific type of neuroma in-continuity. This continuity and is infiltrated by a neuroma. Type S fibrosis is a
neuroma is characterized by a neurofibrous union between the Sunderland class IV injury that is maintained only by scar
epineurium and lingual peristeum of the mandible usually in tissue band and neurorrhaphy or graft reconstruction [12].
the third molar region. The neuroma in-continuity can also Classification of damage by location of the reactive fibrosis:
result from scarring at the site of microsurgical coaptation.

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Designation Location Prognosis

A* Epifascicular epineurium Generally good
B* Interfascicular epineurium Depends on original damage
C* Endoneurium Poor
In a Sunderland class IV injury, the epineural connective tissue
N Poor
that maintains continuity can be infiltrated by a neuroma (IVN)
S Continuity in class IV injury maintained only by scar tissue Poor

Pathophysiologic Classification Transection, Laceration, Repture and Avulsion: This

Compression: Compression injury to a peripheral nerve may constitutes Sunderlands 5th degree injury. Recovery depends
produce a nerpoathic pain syndrome. The acute response of on the approximation and co-adaptation of the nerve ends
compression is inflammation and edema. The first stage in the without tension. The prognosis depends on the nature of the
pathogenesis of nerve compression is blood nerve barrier injury and local factors. Transection and laceration injuries
changes resulting in subperineural and endoneurial edema. are generally associated with less tissue destruction than
This leads to connective tissue changes that include rupture or avulsion injuries and therefore have a better
perineurial and epineurial thickening. Next stage in prognosis. The scar tissue within the between the nerve ends
pathogenesis is the localized nerve fiber changes. Some fibers interferes with the advancement of the axonal growth cone.
within he nerve trunk function normally where as others will Those factors that minimize scar formation will improve the
exhibit segmental demyelination. As the degree or duration of prognosis. The prognosis for Sunderland fifth-degree injuries
compression increases, Wallerian degeneration will be is better for intraosseous nerves than for soft tissue nerves.
apparent. The peripheral fasciles and nerve fibers will be Surgical reconstruction of infraosseous nerve should be
more affected first where as more centrally located fascicles delayed when the neuro vascular canal is intact. The
and nerve fibers may be spared. The mechanism of reconstruction should be predicated on the functional
compression injuries includes both mechanical deforming recovery of the nerve as determined by sequential sensory
forces and ischemic factors. evaluations. Surgical reconstruction of soft tissue nerve
should be performed early because the prognosis is poor and
Compartment Syndrome: The nerve injury associated with the local factors unfavorable [12]
compartment syndrome is similar to that seen with nerve
compression except that the effects are largely due to Chemical Injuries: Most often the result endodntic therapy
ischemia of the nerve caused by diminished flow within the dry socket packing or chemical neurolysis. Very little
compartment. The compartment syndrome may apply to the information is available regarding the pathophysilogy of these
inf. alveolar, descending palatine and infraorbital nerves. injuries. Some of the offending agents include eugenol,
Increased venomous pressure results from increased local alcohol, phenol, and paraformaldehyde-containing endodontic
tissue pressure, such as from edema and inflammation of the filling materials. The greatest variable is the depth of
nerve trunk. This leads to a decrease in the local arterioneous intraneural penetration of any of these chemicals. The initial
gradient diminished blood flow, decreased oxygen delivery to response following exposure of a nerve to a chemical is
the nerve. The reversibility of these changes will be inflammation. This may initiate a compartment syndrome for
determined by the amount of tissue pressure and the duration intraosseous nerves. The severity of fibrosis and nerve fiber
of the pressure. As with the compression injury, the large A  dysfunction will depend on the duration of exposure, depth of
nerve fibers are most susceptible to the ischemic changes. intraneural penetration, and toxicity of the chemical. The
Clinically the first sign is abnormal vibration and touch management should begin with identification of the chemical
perception. The management is by – immediate and determination of the neurotoxicity. Chemical exposure of
decompression of the compartment and VSE of an intraosseous nerve should be managed as a compartment
pharmacological agent to alleviate inflammation and edema syndrome. Surgical reconstruction of chemical nerve injury
of the nerve trunk, such as steroids and anti-inflammatory should be delayed because of the variability and
drugs. unpredictability of the injury pattern [13].

Stretch Injury: Stretch or fraction injuries truly demonstrate Nerve Injection Injury: Unexplained sensory disturbances
a three dimensional injury pattern. The degree of injury varies following an intra-oral surgical procedure, especially
not only from fascicle to fascicle but also in a longitudinal odentectomy may be blamed on the local anesthetic injection.
manner along the length of the nerve. Surgical exploration of Histologic studies in animal shows that needle denetration to
stretch injuries mandates exposure of a considerable length of an nerve trunk causes minimal nerve injury and results in no
nerve so as not to miss a damaged area. The sequence of long lasting alteration histologic or physiologic character of
changes associated with nerve stretch is not completely the nerve However, the intraneutral injection of drugs and
understood. Sunderland feels the sequence of tissue rupture chemical does result in severe and irreversible nerve damages.
begins with axonal rupture (second-degree injury) followed in Recent evidence suggests that enzymatic hydrolysis of L.A.
sequence by rupture of the endoneurial tubes (third-degree agent into a drug metabolite and alcohol may cause a
injury), perineurium (fourth-degree injury), and finally persistent neurosensory deficit. Any symptoms of paresthesia
endoneurial rupture (fifth-degree injury). Early surgical when injecting the awake patient should alert the physician
exploration of a stretch injury is warranted to establish the that the needle may have penetrated the nerve. The needle
diagnosis and rule out an avulsion but surgical reconstruction should be immediately withdrawn until the paresthesia has
should be delayed in all cases. Early reconstruction of a subsided. The diagnosis of an infection injury relies on the
stretch injury may result in missing or “skipping” a lesion, history. Generally the patient may complain of severe
unnecessarily exiting a damaged segment or failing to excise immediate pain that radiates into the sensory field of the nerve
a damaged segment [13]. being blocked

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Central Neuropathy: Nerve injuries may results in of 0.5-7 m diameter are assessed. If blunt points are used,
debilitating central neuropathies such as a typical facial pain the larger myelinated Alpha afferent fibers of 5-15 m
and pain resulting from deafferentation. The diagnosis of the diameter are assessed. Campbell et al reported that normal
central neuropathies can be quite difficult but extremely measures for two-point discrimination in the TN distribution
important because surgical reconstruction of the injured nerve vary from 7 to 14 mm, it is considered diminished at from 15
rarely offers improvement and in some instances may to 20 mm and absent above 20 mm. ECG calipers or a Boley
exacerbate the pain. No single therapy has proved effective in gauge works well for this test with the patient eyes closed the
managing this type of injury. Supportive measure include – test is initiated with the points essentially touching. So that
antidepressants, anti-convulsants, transcutaneous the patient is able to discriminate only one point. The distance
neurostimulation, physical therapy, biofeedback, acupuncture, between the points is increased in 2-mm increments until the
relaxation therapy, psychotherapy and management in the patient is able to discriminate two distinct and separate points
setting of a comprehensive multidisciplinary pain clinic.14 in at least four or five trials with the points widely separated,
the points are moved closer together until the patient is able to
Clinical Evaluation of Nerve Injuries discriminate only one point. Record the separation of the two
Basic clinical neurosensory examination of the TN consists of patients, whether or not the patient could distinguish two
4 tests: Static light touch, Brush directional discrimination, points at any time and the patient’s perception of the stimulus
Two-point discrimination, Pin pressure nociceptive [14]
.
discrimination. The patient is comfortably seated in the Pin pressure nociception: This test assesses the free nerve
semireclined position in a quiet, temperature-controlled room endings and the small A-delta and C-fibers that innervate the
[14]
. free nerve endings responsible for nociception. For this test a
Static light touch detection: Assesses the integrity of the pressure algesimeter is used. This instrument is easily made
Merkel cell and Ruffini ending, which are innervated by from a no. 4 Taylor’s needle and an orthodontic strain gauge
myelinated afferent axons of 5-15 m in diameter (A-beta). (15-150 gm). Needle is applied perpendicular to the skin of an
These receptors adapt slowly, and their putative sensory unaffected area and the force is increased over 1-2 secs until
modality is pressure. Test is performed using Weinstein – the desired level is reached, held constant for 1-2 secs and
Semmes filaments, which are nylon filaments of identical slowly removed over 1-2 sec period. First the needle is
lengths but variable diameters mounted in plastic handles. applied with sufficient force so the patient precious 
Keep the filament vertically oriented and above the cutaneous pricking sensation (15-25 gm). Some force is applied to
area to be stimulated. Slowly place the tip of the filament on affected region and the patient is asked to choose one of 4
the skin continue the pressure without movement for 1 second adjectives (touch, pricking, stinging, stabbing) that best
and 1 to 1.5 sec slowly raise the filament. If patient reports describes his perception. The nociceptive threshold for the
touch during the application period, discard this affected area is determined. The force is gradually increased
approximation trial and select a filament two to three steps on the affected areas until the sharpness of the pin is identical
lower on the scale and repeat the procedure for a filament to to that of the unaffected area just tested. The magnitude of
which there is no response, continue with filaments of force necessary to equal the sharpness of the unaffected area
increasingly greater stiffness until the patient responds. is recorded as the nociceptive threshold for the affected area.
Record this filament value as the first ascending If there is no response at100 gm pressure, the area is
determination. Then select a filament two to four steps above considered to be anesthetic.
the one felt by the patient apply this in the same fashion to the
same spot on the skin. If there is no response, select filaments Thermal Discrimination: Thermal discrimination is a useful
two steps above that one and repeat the procedure. If the adjunctive test of sensation but is not essential. This is a test
patient reports ‘touch’ continue applying filaments of of small-diameter myelinated and unmyelinated fibers.
decreasing stiffness in the same manna until there is no Similar to those tested for pin pressure. Warmth sensation 
response. Record as the descending value the last filament A-delta fibers. Cold sensation  C-fibers. Various
that was perceived by the patient [14]. instrumentation available for thermal testing: thermodes and
Brush directional discrimination: This is a test of Minnesota Thermal Disks (MTD), ice, ethylchloride sprays,
proprioception and assesses the integrity of large A-alpha and acetone and water. Cotton swab saturated with either ethyl
A-beta myelinated axons that innervate the lonceolate endings chloride or acetone is applied to the skin and the patient is
and pacini and meissner corpuscles. The putative sensory asked to mark on a visual analogue scale the magnitude of
modalities for these receptors are vibration, touch and flutter. temperature perceived and whether or not the stimulus was
With the patients eyes closed, the least stiff Weinstein- painful or uncomfortable. Minnesota thermal disks (MTD)
Semmes filament detected from the static light touch can be used for thermal discrimination. There are four disks
thresholds or a 00 Camel’s – Hair brush is gently stroked over made of copper (C); stainless steel (S) glass (G), and
a 1-cm area of skin at a constant rate. The patient is asked if polyvinyl chloride (P). Copper is the coldest stimulus and S,
any sensation is detected and in which direction the filament G and P are progressively less cold. Normally, C is readily
or brush moved. The correct no. of responses for the total no. recognized as cooler than P. Most normal individuals can
of trials is recorded. It is important to note whether or not any recognize C as cooler than G and few can recognize C as
sensation was detected. No correct responses because no cooler than S. The difference between C and P is there order
sensation was detected a more ominous. Finding than no magnitude, C and G two and C and S one. Testing is
correct responses because the direction of most could not be performed by applying or series of paired MTD to the face
accurately determined in spite of stimulus detection. and asking the patient to determine for each sever which of
Two-point discrimination: This is a test of tactilegnosis which two MTD is cooler. There are 10 possible pairs of thermal
assesses the quantity and density of functional sensory stimuli, but for convenience only thus pairs are used; C and P;
receptors and afferent fibers. If sharp points are used, the C and G; C and S. Factors influencing the timing and results
small myelinated A-delta and unmyelinated C-afferent fibers of nerve repair. There are several well identified factors that
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have a definite bearing on the timing of nerve repair and the  weekly sensory examinations are performed for 1 month,
results of motor and sensory returns following repair. Age: A then manly for 5 months. If neurons or neuropathic pain. First
number of authors have reported on the increased rate and line of treatment – nerve blocks, analgesis and TENS. If pain
quality of recovery following nerve repair in children and dies not resolve  after 3-4 week treatment  microsurgical
even in young adults, repair in children under 6 years of age exploration and repair. Compression and stretch injury:
there is excellent recovery of sensibility in all cases, after the Immediate decompression and alternation of stretch to
age of 6 years there is a steady decrease in functional return prevent ischemic and mechanical trauma. Serial sensory
with the two point discrimination value expressed in examination weekly for 1 month and then once a month for 5
millimeters being about the same as the age of the patient mos [7].
upto 20-31 years of age the sensory recovery varied but
tended to be poor above 31 years of age all the results were Unobserved Injuries: Offers the greatest diagnostic
poor with a 2 PD near or above 30mm. Type of trauma: challenge because exact anatomic nature of injury is usually
Gunshot wounds, high speed missile wounds and any trauma not known. Monitor area of sensory loss/disturb for 1 month.
that stretches a nerve cause severe nerve injuries both at the Neuroplaxia or Sunderland 1st degree injury resolves within
site of wounding and at a distally from this point, this type of 1st month. The monitor monthly basis after 1 mo Sunderland
trauma also causes gross destruction of nerve and other law 2 w and Sunderland degree show the first sign of sensory
tissues, which leads to scarring and a poor bed for the repaired recovery within 2-5 mos. If sensation fails to improve and
nerve, in contrast there are the sharp knife and glass nerve paresthesia persists, microsurgical exploration and repair
injuries that occur most commonly in civilian life, sharpely indicated only if there is a strong suspicion of an extraneural
divided nerves most commonly caused by glass or a knife, irritant is compressing the nerve. Sunderland 2 w and 3 w
involve the nerves only at the site of injury and extend a few degree injury rarely develops sign of dysesthesia. 4th and 5th
millimieters proximally and distally. Level of nerve injury: degree injuries have poor prognosis for sensory recovery and
The rapidity and quality of sensory and motor function are more likely to develop signs of dyesthesia. Dysesthesia
following high nerve injury is not as good as following lower should be managed immediately. If anesthesia persists for 3-5
injury, reasons for this are the greater loss of nerve cell mass months after nerve injury and this is unacceptable to the
as discussed under the heading of metabolic changes of nerve patient, then microsurgical exploration and repair are
cell the more equal proportion of motor and sensory fibers at indicated. Indications for microreconstructive surgeries:
higher levels and thus the greater chances of cross Painful conditions with a peripheral locus characterized by
innervation, particularly in the median nerve, the greater allodynia and hyperpathia. Prevention of available post-
distance the axons must travel to reach muscle in high lesions, traumatic sensory disturbances. Anesthesia that is
which gives more time for the denervation changes in muscle objectionable to the patient. Surgical management of lingual
that limit restoration of function and the more destructive nerve injuries: Injury to lingual nerve can occur during
types of trauma that tend to occur at higher levels. Primary routine oral surgical procedures such as 3rd molar
versus secondary repair: It can be stated that peripheral nerves odontectomy, orthognathic surgery and even local anesthetic
severed by gunshot wounds, high speed missiles or streching block injections, the most common procedure asociated with
are best treated by secondary repair approximately 2-3 weeks lingual nerve injury is the removal of impacted mandibular
after injury, it can also be stated that peripheral nerve severed 3rd molars, in those instances in which the lingual nerve is
by sharp glass or knives or other well localized trauma at a positioned high in the alveolar crest and first medial to the
lower level are best treated on the day of injury or within first lingual plate, the lingual nerve is particularly vulnerable to
ten days. Technique of nerve repair: Grabb has shown in a injury, cadaver studies have established that this is normal
controlled study in primary repaired median and ulnar nerves variation in position of lingual nerve is present in 10% of
in monkeys that funicular suture with alignment of funiculi by humans. Surgical management: Exploration and repair of the
their size and position gave a significantly greater degree of lingual nerve can only be accomplished through an intraoral
return of motor function than did nerves sutured by epineural approach. The incision should begin laterally at the base of
technique, he further showed that alignment of the funiculi on the ramus and continue anteriorly to the midportion of the
the cut ends and position was as satisfactory as aligning the distal and buccal region of the mandibular 2nd molar. The
funiculi by the more complex method of identifying the more incision carried around the distal aspect of the second molar
motor and more sensory funiculi by their electrical properties, to lingual side and continued anteriorly within the lingual
the ability of the surgeon performing the nerve repair gingival sulcus to the canine region. A periosteal elevator is
undoubtedly has a direct relationship on the results, although then used to elevate a subperiosteal lingual flap from the
this has not been studied in a scientifically controlled manner medial aspect of the ramus to canine region, because of scar
[15] formation, the elvation of the soft issue flap in the region of
recent 3rd molar extraction is typically difficult and requires
Management of Nerve Injuries more careful dissection, dissection of the gingiva along the
The first step is to classify the injury as observed or posterior and lateral aspect of the 2nd molar should be
unobserved. Treatment of the observed injury may be initiated avoided because this will provide a secure fixation point
immediately, whereas the unobserved injury may need to be during closure the lingual flap is gently retracted medially to
monitored for a period of time before definitive treatment is expose the lingual nerve that is located just beneath the
initiated. The timing of nerve repair may be classified as- lingual periosteum, dense scar tissue at the site of soft tissue
primary, delayed primary or secondary. Primary nerve repairs trauma makes identification of the nerve difficult it is usually
are completed within hours of the injury, delayed primary helpful to identify a normal segment of lingual nerve at a
repair 14-21 days following injury and secondary repair more point proximal and distal to the site of injury and dissect
than 3 weeks following surgery [8]. toward the injury site. Once the nerve has been identified,
gentle retraction applied to the nerve with vessel loops or
Observed Injury: Transected nerves: Sutured primarily but umbilical tape to facilitate a complete dissection, bleeding
nerve grafted primarily. Following initial exploration or repair should be addressed with a fine bipolar cautery, the integrity
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of nerve is assessed with magnifying loupes, can be more might be split to permit the nerve bundle to escape its
assessed by incising epineurium and exposing the nerve anatomy it would be difficult to attempt to surgically sever
fasicles, microdissection is then used to remove any and reanastomose a nerve to free such a tooth. A sagittal split
intrafascicular scar tissue if there is physical disruption of the type of approach was advocated early in the course of nerve
nerve or if a large neuroma is present, resection of the repair because of the ability of this method to expose not only
damaged segment is necessary resection of nerve tissue at the the IAN at its area of primary injury, but also the distal nerve
proximal and distal stumps is continued until normal, viable extent it was originally described using the transoral
fascicles are observed. A tension free primary anastomosis is approach. The proximal nerve exposure was less of a
surgical goal. The proximal segment is exposed and problem, but exteriorization of the IAN distal to the third
mobilized posteriorly through the pterygoid space, the distal molar socket is what made this method attractive. Freezing
segment is mobilized anteriorly to the point where the nerve the distal nerve, including the mental nerve, added
crosses the submandibular duct; if further mobilization of the considerable surgical length, thus aiding in the primary repair
distal segment is necessary then the small sensory branches of of the nerve. The problem with this approach was its overall
lingual gingiva may be sacrificed when maximal mobilization morbidity and difficulty interestingly, this is the equivalent of
of the nerve has been achieved the nerve gap is then assessed. gaining length of the lingual nerve by dissection of the
Nerve gaps measuring upto 1.5cms can usually be proximal nerve, with the limiting factor being the branch to
approximated with minimal tension following maximal the lingual gingiva. One very good indication for sagittal
mobilization. The nerve is stabilized during suturing process approach or other transoral method was for the repositioning
by using a microvascular clamp or 7-0 prolen traction suture of the IAN in implant cases in which the length of the implant
placed within the epineurium at a point proximal and distal to and its potential position put the nerve at risk. The indications
the anastomosis the anastomosis of the proximal and distal for this technique have lessened due to - (1) The use of
stumps is now achieved by placing three or four 8-0 nylon computerized imaging method to better describe the mandible
sutures within the epineurium, sutures should not be placed in 3 dimensions, (2) The use of improved shorter implants and
deeper than the epineiurium which could cause additional (3) The evidence that nerve repositioning carries with it the
intraneural scarring, if the proximal and distal segments same incidence of paresthesia as posterio implant placement
cannot be reapproximated without tension, then an without nerve repositioning about 6%. An extra-oral approach
interpositional graft is indicated, the graft length should be for IAN is simple, direct and gives good access. Direct access
several milimeters larger than the size of the gap to assure that to the injured nerve is achieved by cutting out a cortical
a tension free repair is achieved. The lingual flap is window of the bone after a standard Risdon approach to the
repositioned against the mandible and sutured in place, the mandible. The best method uses a power drill to outline the
first and most important closing suture is placed at the distal area, taking the cut down to bleeding medullary bone, small
aspect of the second molar in the lateral mucoperiosteum that curved osteotomes are then placed at an angle into the cut,
has not been mobilized. This secures the lingual flap and and the separation of inner cortex from medullary bone is then
prevents it from overdoing the occlusal surface of the carefully performed. Once the window of bone is lifted free,
posterior mandibular teeth. The sutures in the dentate portion the marrow bone is dissected carefully using a small straight
of the mandible should be placed interdentally through the dental curette experience helps in identifying the canal and
dental papilla, although patients can quickly resume normal freeing both the pathology and normal nerve present, the
activity following this procedure, they are instructed not to actual extent of the cortical window can be enlarged as
open their mouth maximally for 2-3 weeks so that tension needed. The bone overlying the canal is moved with curettes
across the suture line can be minimized [13]. and the bundle exposed [14].

Surgical Management of Inferior Alveolar Nerve Injuries Surgical Treatment of Maxillary Nerve Injuries: The
Etiology and Incidence: The goal is to present different infraorbital nerve: The oral and maxillofacial surgeon is likely
methods of approaching repair of the inferior alveolar nerve to encounter patients with nonpainful altered sensation or
after injury prior to implant placement by nerve repositioning. dysesthesia secondary to injury to the infraorbital nerve, a
Data for incidence of inferior alveolar nerve injury suggest an distal brand of the second division of trigeminal nerve.
overall risk of 0.5% to 5% in most cases the injured nerve Patients may note abnormal sensations, most commonly in
recovers spontaneously, but the rate of permanent injury cheek and upper lip, typical sensory complaints include
ranges from 0 to 0.9%. The most importnat consideration in numbness, tingling, becoming, itching, crawling, swelling,
assessing the risk of injury is the association of the roots of shocking and temporary or persisatent pain. Behavior
the impacted tooth with the inferior alveolar canal complaints might relate to undesirable changes in kissing,
considerations of the usual two dimensional nature of the speaking biting, chewing or drinking. Etiology and Incidence
radiographic interpretation has led to few guidelines to help of infraorbital nerve injury: Infraorbital nerve dysfunction
the surgeon better inform the patient on the likelihood of post- ranges from complete anaesthesia to a lesser degree of altered
operative paresthesia, the usual complication, or course, sensation and affects 25-80% of trauma patients with zygoma
anesthesia due to severance of the neurovascular bundle. fractures, fractures of zygoma may impact the infraorbital
Surgical approaches: There are three potential approaches to nerve along the floor of the orbit either through an adjacent to
the IAN: one extraoral and two intra oral methods (one the infraorbital foramen of the maxilla, resulting in altered
through the socket itself and the other a sagittal split of the neural conduction due to ischemia compression or transection,
mandible to gain accesses. The use of surgical microscope or severe fractures with more displacement or communication
high power loupes is highly recommended. Going through the are associated with a higher incidence of ION injury-edema
socket represents the most direct approach its main advantage and ischemia localized to the course of the ION, even in the
would be during the initial procedure. Thus an IAN bundle absence of bony impingement, has the potential to alter
runing through roots would manifest as an “object on a string” normal nerve function. The lefort I maxillary osteotomy a
using the same approach as for the odontectomy, the tooth relatively common procedure performed by the oral and
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maxillofacial surgeon can be associated with postsurgical craniomaxillofacial trauma are destined to encounter injuries
altered sensation in the distribution of the ION. Several other to the facial nerve. However in patients with head injuries or
sources of injury to ION or patients complaints have been in the multisystem injured patient, delay in diagnosis and
documented. Orbital decompression for ophthalmopathy has therefore treatment of facial nerve injury can result from
been associated with distressing hypersthesia in the inability to visualize the patients facial expression caused by
infraorbital region upto 15% of patients reconstruction of the altered consciousness or the need for neuromuscular blockade
orbital floor or infraorbital rim after trauma may damage the or sedation, facial nerve compression. This topic is not
ION pathology such as squamous cell carcinoma in the relevant and therefore focused on the management of
vicinity of the ION, may likewise lead to a numb cheek and extracranial facial nerve injuries. Facial nerve injury related to
upper lip in rare instances the subperiosteal face lift soft tissue laceration or avulsion make up the majority of
procedures can injure the ION. Dental procedures ranging extracranial facial nerve injuries. Location of the injury must
from L.A. infections to endodontic treatment also can result in be determined accurately because it can significantly
ION damage. Surgical approaches to the infra-orbital nerve. influence management. Parotid injury is commonly associated
Following the surgical management of ION injury if not with extracranial facial nerve injuries.
managed properly long term pain may develop or if pain is
present prior to surgery, it might returns and possibly worsen Neurorrhaphy: Direct repair of the facial nerve should be
perioperative antibiotics should be administered coverage of accomplished by a skilled microsurgeon under optimal
micro-organisms from the oral cavity, maxillary sinus and conditions. Partial parotidectomy is often required to gain
skin may be desirable, pre-operative intravenous steroids help adequate exposure for nerve anastomosis bipolar cautery is
to reduce post-operative swelling and might aid in nerve used where necessary within close proximity to the nerve, a
regeneration. If indicated, extraoral surgical access to the infra bloodless field is required to achieve appropriate visualization
orbital rim allows the surgeon to expose not only the rim but of the nerve ends. The proximal nerve must be identified by
he infra orbital foramen and the orbital floor, the surgeon visual inspection, orientation and depth are they features used
choice of techniques to expose the infra-orbital rim which are to identify the nerve. High levels of magnification and
similar to the cutaneous approaches to this area for open trimming of the nerve allow characterization of the structure
reduction of zygomatic orbital complex fractures infra orbital, at the proximal end. These same procedures and electrical
lower eyelid, blephoroplasty, or transconjunctival type stimulation can be used within 3 days of transection for
incisions are satisfactory options for surgical exposure confirmation of the native of the distal segment. Direct
surgeon experience and preference in conjunction with neurorhaphy is especially indicated when sharps precise
knowledge of advantages and disadvantages of each lacerations of the facial nerve have occurred such as one
technique should guide the practitioner in making a final could see following razor blade, knife or plate glass injury.
decision. However, the lower eyelid or infraorbital incisions The identified segments must be minimally dissected to
may provide more direct access to and wider exposure, the preserve blood supply to the remaining nerve segments, the
foramen and orbital floor. The infra-orbital and lower lid nerve ends are carefully and completely trimmed direct
surgical incisions can be placed within skin lines to minimize simple perineural sutures are used to achieve approximation.
in esthetic postoperative scars. A transfacial approach to the Careful cooptation is necessary to prevent scar tissue in
ION as described by Ziccardi et al may provide the greatest growth during the time of axonal regeneration, nylon or
access to this area, a modification of the ferguson incision is prolene sutures (10-0) are typically used. A surgeon’s knot
reported in which an incision from the nasolabial fold is and 2 additional square throw are adequate the ideal
extended along the alar groove to the medial canthal area and anastomosis uses a minimal number and volume of suture to
connected to a lower lid incision, the reported benefits include limit the inflammatory response to these materials. A toper
maximum visibility of bony and soft tissue components and cut needle has the advantage of being easy to pass while
no oral communication. Nonetheless a scar will result that causing minimal trauma to the nerve. Graft neurorrhaphy: The
might be undesirable for some patients. Following soft tissue procedure of nerve grafting is identical to that of direct nerve
dissection for access to the ION it should still be necessary to repair with the exception of requiring an additional
remove the bone from around the nerve if injury to the nerve anastomosis for each nerve branch treated, autogenous for
is localized at or within the foramen, or is localized to the each nerve branch treated, autogenous nerve graft remain the
floor of the orbit and the nerve is covered by bone, then standard against which all other treatment are compared,
osteotomy will be necessary maintenance of the infraorbital tubulization with alloplastic materials remains a procedure
rim, if possible is preferred for cosmetic concerns. A small most applicable and appropriate to the experimental
fissure or round bur and small osteotomies, can be used to microsurgical procedure, generally nerve grafting is required
accomplish this procedure, copious irrigation and core to following avulsive type of injuries. Nerve graft donor sites
avoid damaging the nerve with the bur must be used. commonly used include greater auricular nerve, sural nerve
Visualization of the nerve may indicate compression, and more recently the antebrachial cutaneous nerve. The great
stricture, transection or neuroma formation surgical procedure auricular nerve is most commonly used when the total length
to the nerve itself may include neurolysis, resection of of nerve graft required is small, its proximity to the operative
neuroma or scar tissue, primary anastomosis or potentially a field and its exposure in the course of performing superficial
nerve graft, any suturing should be done with a small parotidectomy are major contributing factors the size and
diameter nylon monafilament with 3-4 sutures, shape of the nerve is most compatible to the more proximal
circumferentially placed through the epineurium if a graft is segments of the facial nerve the several nerve is generally
needed, the greater auricular nerve with a fascicular area of used following extensive injuries or resections of multiple
0.82 mm2 better approximates the size of the infra-orbital facial nerve branches its abundant length is certainly
nerve than other nerves [15]. advantage in such cases, the antebrachial cutaneous nerve has
Surgical management of facial nerve injuries: Surgeons advantage in that its structured in the proximal forearm
involved in the comprehensive management of complex involves many branches of the facial nerve in such instances a
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single proximal anastomosis is combined with multiple distal the production by the laser of singlet oxygen, which has been
anastomosis to critical facial nerve branches the reproducible shown in vitro to low concentrations to modulate intra cellular
result of nerve graft reconstruction of facial nerve defects can biochemical processes associated with mitosis.
be best appreciated by comparing the procedure to immediate
grafting of the facial nerve in radical parotidectomy [15]. Electromagnetic Stimulation: Almajed and coleagues
showed in a rat model of a cut and reapproximated femoral
Acceleration of recovery after nerve inujury to the nerve that as little as 1 hour of electric stimulation proximal
peripheral nervous system using ultrasound and other cut immediatley after reconnection caused all the motor axons
therapeutic modalities to progress down their regeneration pathway a given distance
Peripheral neuropathy caused by injury or disease is a in 3 weeks rather than the 8-10 weeks required by the control
common clinical problem often associated with significant animals, their histologic analysis is consistent with electric
motor or sensory deficits, pain and other unpleasant stimulation causing the axons to grow more quickly than they
sensations recovery can be slow and incomplete leading to would without stimulation, as determined by counting the
personal hardship for patient and significant costs to society at axons with a black labeling technique, their data are also
large. The severity, or grade, of a peripheral nerve injury is consistent with the hypothesis that electric stimulation
one of the most important correlates with recovery for accelerates the progressive reinnervation of appropriate
example, in a neuraproxia grade of injury such as those that axonal pathways by the motor neurons at least moreover
arise as a result of mild to moderate acute injuries and chronic when tetrathodoxin was applied to the proximal portion of the
entrapment neuropathies, there is usually demyelination of the cut nerves at a sufficient dose to block electric signals evoked
nerve with preservation of the axons. Acute and chronic in the cell body by the electric stimulation, the stimulation
injuries of greater magnitude or produce degeneration of had no therapeutic effect, the tetradotoxin assay indicates that
nerve fibers distal to the site of trauma, these axonotmetic the beneficial action of the electric stimulation starts in the
grades of injuries require not only axonal remyelination but cell body of the regenerating axons, perhaps by accelerating
axonal regeneration for recovery to occur. If the cellular and protein synthesis [14].
extracellular components that form a suitable substrate for Ultrasound: Recent studies demonstrate ultrasound’s efficacy
axonal regeneration are available, as in crush injury, nerve in treating chronic and acute peripheral nerve injuries, in
fibers regenerate at an average rate of approximately 1mm/d human patients suffering from carpal tunnel’s syndrome, for
injuries that require axons to traverse long distances before example, local application of ultrasound 20 times over a 2
reaching their target muscles or sensory receptors can take week period reduced symptoms are improved nerve
upto 2 years for recovery of function current treatments for conduction compared with results in a placebo control group,
disabling nerve injuries involve surgical decompression for even 6 months after the end of treatment similarly in an
entrapment neuropathetis and surgical exploration and repair animal study, the application of ultrasound for 1mm 3 days
after severe trauma, trials of drugs for peripheral per week over 1 month enhanced the recovery of normal
neuropathies, including various neurotrophic factors, have nerve conduction velocity after partial crush injury to the
been unsuccessful to date, despite advances in medicinal and tibial nerve of rats, in particular all electrophysiologic
surgical management of peripheral nerve injuries recovery is measures improved in a statistically significant fashion for the
often incomplete major impediments to a full recovery ultrasound group relative to the control group. The work by
include long delay and associated tissue atrophy and Hong et al motivated Mourod et al, who showed that local
imprecise reinnervation of the targets of the motor and application of ultrasound for 1 min. 3 days per week over 1
sensory nerves it would be clinically beneficial to develop month acceleration the recovery of sciatic nerve function after
new treatment to accelerate and improve the recovery process complete crush injury. Mourad et al found a statistically
[16]
. significant acceleration in recover of gait after complete crush
injury for 2 ultrasound protocols relatively to controls. How
Recent Research on Nonsurgical Treatment of Injured does ultrasound create the effects observed by Hong et al and
Peripheral Nerves Mouard et al, as reviewed by mourad, ultrasound has been
Recent research on treatment of peripheral nerve injury in succesfully used to treat a variety of medical problems,
addition to surgery includes laser treatment, electromagnetic including flesh wounds, bone fractures and several tendons,
stimulation and ultrasound. Laser: Rochkind and Ovaknine typically through the augmentation of protein synthesis; other
reviewed the literature on the use of low-power laser studies have shown an increase in macrophage activity after
irradiation to promote healing in a rat model of acute exposure to ultrasound and still others have shown ultrasound
peripheral nerve injury that often results in damage to the to accelerate angiogenesis - ultrasound therapeutic effect on
neuronal cell body. They applied the light transcutaneously peripheral nerves may be the result of (1) acceleration of
every day for several minutes/session immediately after remyelination or axonal regeneration (2) acceleration of the
surgery, they have worked with a rat model of acute macrophage led portion of the entire degeneration and
peripheral nerve damage that often result in damage to regeneration phases by accelerating the flux of nutrients into
neuronal cell body, they have shown that direct laser and toxins out of injury site. The signal transduction
treatment nerve tissue eventually restores the mechanism that translates the acoustic energy into a biologic
electrophysiologic activity of the injured peripheral nerve and effect is unknown, mortime and Dyson have shown that
prevents degenerative changes in neurons of the spinal cord ultrasound alters Ca++ influx in fibroblasts and changes in
interestingly, they note that treatment must occur within about intracellular Ca++ are often involved in signal transduction
[15]
3 days of injury or there is no discernible effect. This implies .
that the laser stimulation acts on healing processes at work
early in neuron recovery, perhaps by accelerating Surgical Therapy for Traumatised Peripheral Nerves
degeneration or the early stages of axon or myelin Peripheral nerves of the face that have undergone neruopaxia
regeneration. They correlate these therapeutic benefits with or axonotmesis generally spontaneously recover, however
~ 18 ~ 
International Journal of Applied Dental Sciences  
 

there are nerve injuries for which treatment by an oral References

maxillofacial surgeon trained in micro vascular surgery is 1. Converse JM. Introduction to plastic surgery.in: J.M.
warranted. External or internal nerve compression. Intentional Converse (Ed.) Reconstructive plastic surgery. 2nd
or accidental severance of a nerve. Appearance of a traumatic edition. WB Saunders, Philadelphia. 1977; 1:3-68.
neuroma and/or pain syndrome after nerve injury. External 2. Larsson A, Jonsson L, Sjöquist J. Bell's palsy: An
compression of a nerve trunk may result from impingement of immune complex disease. J Otorhinolaryngol Relat Spec.
a bone, tooth root or broken instrument. This external 1990; 52:164.
compression may be visible with special radiographs imaging 3. Wolford LM. Surgical planning in orthognathic surgery.
techniques but frequently depends on explanatory surgery for in: P. Ward Booth, S.A. Schendel, J.E. Hausamen (Eds.)
establishing a diagnosis. Internal compression usually caused Maxillofacial Surgery. 2nd edition. Churchill Livingstone
by growth of scar tissue into the nerve trunk, while it was Elsevier, 2007.
regenerating. Surgical decompression of the treatment of 4. Saraswathi TR. Shafer's textbook of oral pathology. J
choice for either external or internal nerve compression [16]. Oral Maxillofac Pathol 2009; 13:46.
5. Klasser GD, Okeson JP. The clinical usefulness of
Prognosis of Nerve Injuries surface electromyography in the diagnosis and treatment
Likelihood of spontaneous recovery: The likelihood of of temporomandibular disorders. J Am Dent Assoc. 2006;
spontaneous recovery depends on the condition of the nerve, 137:763-771.
the severity of nerve injury and the site of injury a divided 6. Okeson JP. Bell’s orofacial pains. 6th edition.
intraosseous nerve within a well aligned and approximated Quintessence Publishing Co Inc, Chicago; 2005; 595-
canal is more likely to recover spontaneously than is a divided 104.
extraosseous nerve because of the protection and guidance 7. Fonseca Rj, Walker Rv. Oral and maxillofacial trauma.
provided by the canal, divided extraosseous nerves are at risk Philadelphia, Saunders, 1991.
for neuroma formation and dysesthesia or paralysis. Nerves 8. Korean Association of Oral and Maxillofacial Surgery.
that are chronically compressed or stretched will never Textbook of oral and maxillofacial surgery. third edition.
achieve maximal regeneration, therefore exploration and Seoul: Medical and Dental Publishing Co; 2013, 535-
neurolysis are indicated for maximal recovery the 588.
consequences of chronic compression and stretch are fibrosis, 9. Pertes Ra, Gross Sg. Clinical management of
blocked axonal regeneration neuroma formation, dysesthesia, temporomandibular disorders and orofacial pain.
parasthesia, anaesthesia or paralysis intact nerves that have Chicago, Quintessence Pub, 1995.
sustained a severe compressive crush or stretch injury have a 10. Gregg JM. Neurological disorders of the maxillofacial
poor prognosis for spontaneous recovery because of regions. In: Gustav O. Kruger, editor. Textbook of oral
disruption of the fascicles and intraneural hemorrhage [17]. and maxillofacial surgery. Sixth edition. Saint Louis: CV
Clinically these patients will have anesthesia, dysesthesia or Mosby. 1984, 700-742.
paralysis in the distribution of the injured nerve these injuries 11. Temporomandibular joint dysfunction, 106 pages,
are best managed secondarily and even then the surgeon is UOM:39015032356811, 1994, the essentials, Medical,
presented with the dilemma of whether neurolysis or resection Robert G. Jagger, John F. Bates, S. Kopp Killey HC, Kay
reconstruction is the appropriate treatment. Conditions LW, Seward GR, Harris M, McGowan DA, editors. 4th
limiting regeneration: Conditions that will limit or prohibit ed. Oxford, Great Britain: Reed Educational and
regeneration include chronic compression or stretch, divided Professional Publishing Limited, 1989.
nerves in which the nerve ends are not approximated and 12. Orofacial infections. An Outline of Oral Surgery. Part 2,
excessive scarring of either the nerve or tissue bed. 310-30.
Conditions that contribute to excessive scarring and fibrosis 13. Ossoff RH. Laser safety in otolaryngology-head and neck
include infected or contaminated wounds, poorly vascularized surgery: anesthetic and educational consideration for
wounds and wound closure or neurorhaphy under tension. laryngeal surgery, Larygoscope. 1989; 99(8 pt 2 Suppl
Uncertanities: Clinical decisions are made more difficult as 48):1-26.
the number of uncertain variables increases, uncertainities 14. Controversies in oral and maxillofacial surgery
regarding the condition of the nerve and wound are common. Worthington P, Evans JR (eds), with 76 contributors.
Paresthesia and incomplete paralysis are consistent with an Philadelphia, PA, Saunders, illustrations, 1994; 720:457.
intact nerve and carry a favourable prognosis for spontaneous 15. HUPP JR, ELLIS E, TUCKER MR. 4th ed.
recovery. Anesthesia and complete paralysis are associated Contemporary oral and maxillofacial surgery. St. Louis,
with a severe compressive or stretch injuries and division Mo, Mosby Elsevier, 2008.
injury and have a poor prognosis [18]. 16. BAILEY BJ, JOHNSON JT, NEWLANDS SD. Head &
neck surgery--otolaryngology. Philadelphia, PA,
Conclusion Lippincott Williams & Wilkins, 2006.
The comprehensive management of nerve injuries requires a 17. Frostick SP, Yin Q, Kemp GJ. Schwann cells,
surgeon with a number of available methods of reconstruction neurotrophic factors, and peripheral nerve regeneration.
at his or her disposal. Comprehensive evaluation or Microsurgery. 1998; 18:397-405
documentation of injury is required to determine the most 18. Schmidt U, Pilgrim C, Beyer C. Differentiative effects of
appropriate timing and method of surgical intervention. dopamine on striatal neurons involve stimulation of the
Accurate diagnosis and timely intervention are critical in cAMP/PKA pathway. Mol Cell Neurosci. 1998; 11:9-18.
achieving acceptable outcomes. Multidsciplinary
collaborationis occasionally necessary for extremely proximal
injuries. Delayed facial reconstruction by facial reanimation
requires subspecialty skills and necessitates referals to centers
experienced in such procedures.
~ 19 ~