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Tr i g e m i n a l N e r v e I n j u r i e s

Avoidance and Management of


Iatrogenic Injury
Sami A. Nizam II, DMD, MD, Vincent B. Ziccardi, DDS, MD*

KEYWORDS
 Trigeminal nerve injuries  Iatrogenic injury  Dentoalveolar surgery

KEY POINTS
 Neurosensory disturbances after dentoalveolar surgery remain a significant concern for patients
and surgeons.
 Mechanisms of trigeminal nerve injures resulting from dentoalveolar injury include surgical end-
odontic therapy, removal of impacted teeth, local anesthetic nerve blocks, implant placement,
bone grafting, and management of oral and maxillofacial pathology.
 Current literature indicates third molar removal has the highest overall risk for injury to either the
inferior alveolar nerve or lingual nerve, occurring in 0.4% to 22% of cases.
 Iatrogenic injury to the trigeminal nerve can remain a source of concern and litigation even for the
most experienced oral and maxillofacial surgeons.

INTRODUCTION anesthetic nerve blocks, implant placement, bone


grafting, and management of oral and maxillofacial
The specialty of oral and maxillofacial surgery has pathology. Libersa and colleagues1 conducted a
continued to broaden its scope; however, the review of insurance claims from 1988 to 1997 in
most significant aspect of many practices remains France. They grouped nerve injury patients into
dentoalveolar surgery. The specialty’s commit- one of four groups: (1) surgical procedure (removal
ment to maintaining excellence and providing the of teeth excluding third molars, cysts, and nerve
highest standard of care is paramount for patients, blocks), (2) third molar removal, (3) endodontic
and is the overall theme of this issue. Neurosen- treatment, and (4) implant placement. It was deter-
sory disturbances after dentoalveolar surgery mined that third molar removal had the highest inci-
remain a significant concern for patients and sur- dence of injury (40.8%), followed by endodontic
geons. This article focuses on identifying mecha- therapy (35.3%), other surgical procedures
nisms of trigeminal nerve injury and their (20.7%), and implant placement (3.2%). This is
prevalence, pertinent preoperative evaluation, consistent with typical clinical practice in which
strategies to minimize risk, identification of injury third molar removal is the most commonly per-
including sensory testing, indications for referral formed surgical procedure in most oral and maxillo-
to microsurgeons, and a discussion of medical facial surgery offices. In 2011, Renton and Yilmaz2
management options. published their study describing causes of 93
oralmaxsurgery.theclinics.com

Mechanisms of trigeminal nerve injuries resulting lingual nerve injuries and 90 inferior alveolar nerve
from dentoalveolar injury include surgical end- injuries and reported similar findings to the previ-
odontic therapy, removal of impacted teeth, local ously mentioned study. In regards to inferior

Department of Oral and Maxillofacial Surgery, Rutgers University School of Dental Medicine, 110 Bergen
Street, Room B854, Newark, NJ 07103-2400, USA
* Corresponding author.
E-mail address: ziccarvb@sdm.rutgers.edu

Oral Maxillofacial Surg Clin N Am 27 (2015) 411–424


http://dx.doi.org/10.1016/j.coms.2015.04.006
1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
412 Nizam II & Ziccardi

alveolar nerve (IAN) injury, third molar surgery was Panoramic radiograph should be considered a
again the most common (60%), followed by local standard of care in the preoperative evaluation of
anesthetic injections (19%), implants (18%), and patients with impacted third molars. In 1990,
endodontic surgery (18%). The higher prevalence Rood and Shehab5 published their landmark
for implant-related injury likely highlights the article correlating panoramic radiographic imaging
increasing prevalence of implant placement by with potential IAN injury. They described three fac-
nonsurgeons. They also reviewed lingual nerve tors that were considered to indicate high potential
injury in their population and found 73% to be for IAN injury because of proximity of the impacted
caused by third molar removal and 17% by local third molar roots with the IAN. These radiographic
anesthesia injections. findings included radiolucency of the IAN canal
shadow across the root of the impacted molar,
PREOPERATIVE EVALUATION deviation or deflection of the IAN canal, and inter-
ruption of the white line delineating the superior
As with any surgical procedure, patient evaluation and inferior margins of the IAN canal. Two of these
begins with review of chief complaint, medical his- signs are present in the panoramic film depicted in
tory, and physical examination. This should be Fig. 1. Signs that were considered clinically impor-
augmented with appropriate imaging studies. Af- tant were deflection of third molar root by canal
ter data have been collected, a true appreciation and narrowing of third molar root. Many studies
of risks and benefits can be presented to the have confirmed these as reliable indicators of
patient as part of the informed consent process. involvement of the IAN and most practitioners still
Patient selection, indicated procedures, risks, use these criteria in the preoperative evaluation of
and benefits can be discussed with the patient us- patients before third molar surgery.5
ing American Association of Oral and Maxillofacial With the advent and availability of cone-beam
Surgeons Parameters of Care as a guide.3 computed tomography (CBCT), many oral and
Current literature indicates third molar removal maxillofacial surgery practices use this advanced
has the highest overall risk for injury to either the imaging modality in the preoperative risk assess-
inferior alveolar nerve or lingual nerve, occurring ment of patients with complex impacted third
in 0.4% to 22% of cases. This is well appreciated molars. This is not advocated for the routine eval-
by the oral and maxillofacial surgery community uation of every third molar patient because of cost
because there is a significant body of research and radiation exposure; however, it remains a use-
devoted to the issue of trigeminal nerve injury ful supplementary imaging modality in those pa-
including prevention, assessment, and manage- tients identified on panoramic radiographs as
ment. Patients older than age 35 have an increased being high risk for IAN injury because of local pa-
risk of IAN injury presumably from denser cortical thology or the relative position of the impacted
bone, fully developed root structure, concomitant tooth with the IAN canal. Most of the reported
medical conditions, and decreased healing poten-
tial. The type of impaction and operator experience
correlate with increased risk of nerve injury, specif-
ically depth and angulation of the impactions. The
more tissue manipulation and/or bone removal
required correlates with increased risk of injury.
For instance, there is an increased chance of injury
in horizontally impacted teeth when compared with
mesioangular, vertical, or distoangular impactions.
Third molars removed in the operating room under
general anesthesia have also been shown to have
increased chance of injury, presumably from
increased forces and overall more difficult case se-
lection.4 The authors have also hypothesized that
local anesthetic nerve blocks given to patients un-
der general anesthesia could potentially have an
increased incidence of nerve injuries because pa-
tients are unable to respond to injections while un-
der general anesthesia. For this reason, the
authors do not administer nerve blocks to patients Fig. 1. Multiple impacted teeth with root darkening
under general anesthesia, but rather use local infil- at the apex of #18 and diversion at the apex of tooth
tration techniques. #19 evident on panoramic radiograph.
Trigeminal Nerve Injuries 413

research focuses on those patients determined to American Association of Oral and Maxillofacial
be high risk by Rood’s criteria. It is known that Surgeons Parameters of Care states “Indications
exposure or contact of a tooth root with the IAN for cone beam computed tomography for routine
increases the chance of nerve injury 20% to third molar surgery should be documented before
30%.6 Researchers have focused on assessment ordering scans and follow the principles of ALARA
of decortication of the IAN canal by the root of (as low as reasonably achievable),” essentially
the third molar as a risk factor. Nakamori and col- leaving the decision to the surgeon’s discretion.3
leagues7 found that when Rood’s criteria were Lingual nerve injury during third molar removal
present, there was a greater than 50% chance of occurs at a similar rate of 0.4% to 22% of cases.
decortication of the IAN canal. The group MRI studies have elucidated the preoperative po-
cautioned, however, that teeth that were deemed sition of the nerve to be at or above the height of
superimposed and did not meet Rood’s criteria the lingual alveolar crest in 10% of patients and
still had a 32% chance of demonstrating decorti- in contact with the lingual plate in 25% of cases
cation of the canal. Guerrero and colleagues8 in the third molar region.12,13 Fig. 3 demonstrates
examined just this group and determined that an example where a high lingual nerve was
CBCT is more accurate than panoramic radio- damaged during extraction of tooth #32 and sub-
graphs; however, clinically this did not result in a sequently reconstructed. Anatomic factors, such
difference in neurosensory outcome for patients. as lingual angulation of the impacted tooth and
Selvi and colleagues9 recently examined the need for vertical sectioning, increase the risk of
high-risk group of patients and found that in partic- lingual nerve injury.4 Ultrasound has also recently
ular, darkening of the root did correlate with been described as an alternative imaging modality
cortical perforation on CBCT. Furthermore, a for assessing the path of the lingual nerve in this
decortication of the canal greater than 3 mm corre- region. Benninger and coworkers14 using ca-
lated with an increased risk of injury at time of sur- davers described the path of the nerve as traveling
gery.9,10 Fig. 2 presents a sagittal and coronal CT on average 13.2-mm anteriorly from the distolin-
image of the same patient presented in Fig. 1 that gual aspect of the third molar before it turned infe-
was selected for further imaging based on Rood’s rior and medial to innervate the tongue on
criteria. ultrasound studies. They additionally reported the
Proponents of advanced imaging, such as nerve being 7.3-mm inferior to the lingual alveolar
CBCT or traditional CT scanning, state that crest on average, with this number remaining
advanced imaging allows for formulation of surgi- similar between dentate and edentulous patients.
cal plans and therefore avoidance of iatrogenic This 13.2-mm anterior travel along the lingual cor-
injury to the nerve. This is highlighted by Umar tex places it in intimate contact with the second
and colleagues,11 where 200 teeth demonstrating molar site and provides a route for potential iatro-
contact with the IAN on imaging were removed genic injury during third molar surgery.14
with a 12% incidence of temporary hypoesthesia Preoperative evaluation for implant patients also
and no permanent deficits. Opponents argue that begins with thorough physical examination. Bone
there have been no randomized clinical trials stock availability and bone defects can be appre-
demonstrating actual outcome benefit with ciated through bimanual palpation. If a thin ridge
advanced imaging. In light of current controversy is encountered and bone height will be removed
over the role of advanced imaging, the most recent for implant placement, this vertical change needs

Fig. 2. CT scan images of the patient


in Fig. 1. Note the loss of decortica-
tion of the canal on teeth #18 and
#19. The inferior alveolar nerve is
noted to be present in the notched
apex of impacted tooth.
414 Nizam II & Ziccardi

establishing bone heights for better mechanical


stability of implants. CBCT and other implant plan-
ning software could also be used to position
implants buccal or lingual relative to the IAN canal
if indicated.
A similar algorithm can be developed for
implants placed in the mental foramen region,
the only difference being the placement of
implants anterior to the foramen because of a
possible anterior loop of the nerve before exit
from the bony canal. Greenstein and colleagues16
Fig. 3. Example of lingual nerve above the lingual reviewed the literature on this subject and found a
crest (10% incidence), which was subsequently injured wide variance of not only presence of the anterior
during extraction of tooth #32. The nerve has been re- loop but also its distance when it exists. If a
paired after excision of neuroma and covered with planned implant osteotomy encroaches within 2-
Neuragen collagen conduit from Integra Life Sciences
mm superiorly or anterior to the mental foramen,
(Plainsboro, NJ).
they suggest two options: CBCT or surgically
probing the canal with a Nabers 2N probe at
to be factored into the final height of bone avail- time of surgery. The key to probing is to probe
able for implant placement. As with third molar the distal aspect of the foramen. If it is not patent,
removal, panoramic imaging remains clinically this means the nerve enters from an anterior to
useful for the initial evaluation of implant patients posterior region signifying an anterior loop. This
with the understanding that distortion can create same procedure cannot be performed probing
inaccuracy of up to 25%. Standardization can be anterior in the foramen because the incisive
accomplished by placing a known-size metallic portion of the canal will be probed. The authors
object in the area of interest and accounting for advocate maintaining a distance of 5-mm anterior
distortion based on actual measurements of the to the visible mental foramina to avoid injuries to
metallic object. Once the radiograph is taken, a the anterior loop of the IAN.
simple conversion formula can be used to deter- Planning for periradicular endodontic surgery in
mine actual bone height ([radiographic bone the posterior mandible starts as described previ-
height/radiographic marker size] x [N/actual ously with physical examination including neuro-
marker size], where N is actual bone height). A 2- logic examination. Although rare, numerous
mm margin of safety should be minimally main- reports exist of periapical infection and inflamma-
tained above the IAN canal. If this margin is not tion producing temporary neurosensory distur-
available or poor visualization of the nerve is pre- bances. This may occur because of roots of the
sent, then an advanced imaging technique, such premolars and distal root of the second molar hav-
as CBCT, should be considered.15 Fig. 4 shows ing close proximity to the IAN with inflammation or
an instance where a 2-mm safety margin was not pathology at the apex.17 This provides clinical in-
maintained at time of implant placement. Alterna- formation as to the indication of close involvement
tively, bone augmentation of the deficient ridge is of the IAN and the possibility of a more serious
an option to be discussed with patients in re- cause, such as malignancy, to be ruled out with

Fig. 4. (A) Panoramic image of patient with bilateral IAN damage caused by improper planning before placement
of ceramic implants. Also note osteotomy shadows bilaterally, which represent temporary implants removed by
secondary surgeon that also contributed to nerve injury. (B) Same patient demonstrating bilateral compression of
the IAN at the mental foramen and body region.
Trigeminal Nerve Injuries 415

laboratory assessment of pathologic tissues. Vel- intraoperatively, which can be protected by


vart and coworkers18 examined a series of 78 covering with resorbable gelatin sponge.
patients scheduled for periradicular endodontic For routine extractions, a plan is formulated that
surgery and found definitive identification of the allows the least amount of force, trauma, and
IAN in only half of these patients and evidence of development of postoperative edema to be placed
the periapical lesion in only 61 of the 78 patients. on the neurovascular bundle. Preoperative ste-
They suggested if the mandibular canal cannot roids have been found in small studies to attenuate
be detected in imaging or is in close proximity, sensory disturbances after extraction of third mo-
CT scan should be used to delineate the existing lars.19 Additionally, nonsteroidal anti-inflammatory
anatomy and provide the added benefit of eluci- drugs (NSAIDs), in particular diclofenac, have
dating the three-dimensional anatomy around the been shown by Shanti and coworkers20 2013 to
tooth apex.18 Fig. 5 depicts the postoperative attenuate post–sciatic nerve injury in a rat model.
panoramic radiograph of a patient who underwent The combination of dexamethasone and diclofe-
apicoectomy of tooth #19 with injury to the IAN. nac was studied in 2005 with a preoperative
dose of 8-mg dexamethasone and 50-mg diclofe-
nac and a postoperative dose of 4-mg dexameth-
SURGICAL STRATEGIES FOR AVOIDANCE OF asone and continued 5-mg diclofenac two times a
INJURIES day for 5 days. The combination was found to be
synergistic when compared with either agent
After risk stratification using the previously
alone and provided statistically significant
mentioned methods, discussion with the patient
decrease in short-term pain and swelling.21 Pro-
occurs to decide on the particular surgical proce-
phylactic antibiotics have recently been demon-
dure to be performed. If the patient fits into a
strated in the Cochrane database to prevent
high-risk category for any of the previously
complications after extractions of third molars.22
mentioned reasons and there is no active pathol-
In light of the data, and the added benefits of pa-
ogy associated with impacted teeth, partial inten-
tient comfort, it seems reasonable that a preoper-
tional odontectomy or orthodontic extrusion
ative dose of steroids, NSAID, and antibiotic may
should be considered. Surgeon experience has
be advised before undertaking complex third
also been found linked to lower incidence of post-
molar impaction surgery.
operative neurosensory deficits.4 For the experi-
Complex impacted tooth removal may require
enced surgeon, a traditional extraction may still
the use of releasing incisions. On designing the in-
be attempted with good outcome if the prior stated
cisions, the surgeon must also pay particular atten-
algorithm is used and no absolute contraindica-
tion to the lingual crest because of variability in the
tions to extraction exist.11 The authors often use
position of the lingual nerve necessitating a disto-
this approach after advanced imaging with surgery
buccal release to avoid nerve injury.13 In rare cir-
performed in the operating room under general
cumstances, the nerve may take a path across
anesthesia to allow potential repair of any wit-
the retromolar pad, in which case lingual nerve
nessed nerve injury at the time of surgery. These
injury is almost unavoidable in even the most skilled
cases often demonstrate exposure of the nerve
hands. Once a surgical flap is developed, a subper-
iosteal dissection is undertaken. If the preoperative
plan dictates need for distal bone removal, a lingual
flap may be retracted for better visualization and
protection of the lingual nerve. This technique has
been shown to result in higher temporary neurosen-
sory disturbance but no increase in long-term
disturbance (something that should be disclosed
during the consent process).23 The surgical plan
is then carried out with appropriate troughing of
the bone to the level of the cementoenamel junction
to allow for visualization and performance of
sectioning with caution not to encroach on the
lingual plate. Once the crown is sectioned and
removed, roots can be delivered with minimal force
to allow for copious socket irrigation. A visual
Fig. 5. Apicoectomy was performed on this patient assessment of the socket is then undertaken noting
without the use of advanced imaging despite close any lingual perforation or exposure of the IAN neu-
proximity to the IAN nerve resulting in nerve injury. rovascular bundle, which should also be noted in
416 Nizam II & Ziccardi

the patient record. It may be advised to document Partial intentional odontectomy or coronectomy
pertinent negative findings at this time, such as provides another option (discussed elsewhere in
intact lingual plate, no bone fractures, no active this issue). Contraindications for intentional partial
bleeding from socket, and no visualization of the odontectomy include significant medical comor-
IAN noted. Fig. 6 presents intraoperative photo- bidities, such as immunocompromization, patients
graphs of the same patient in Figs. 1 and 2. Wide planned for or having received radiation therapy,
access was obtained with releasing incisions in patients with poorly controlled diabetes, and the
an operative room setting with the patient under presence of local pathology that contradicts use
general anesthesia. Note the exposure of the IAN of this technique.27 Horizontally impacted teeth
as preoperative CT predicted. The site was recon- have been reported as a relative contraindication,
structed using gelatin sponge as a protective bar- although a recent article by Monaco and col-
rier over the nerve and then grafted with leagues28 reporting on this technique found no
allogeneic bone and finally collagen membrane. complications when treating horizontal impactions.
If control of hemorrhage becomes necessary, Orthodontic extrusion is another potential op-
the appropriate agent must be selected. Alkan tion for extraction of third molars at high risk; how-
and colleagues24 reviewed four commonly used ever, the authors have minimal experience with
hemostatic agents and found oxidized regener- this techniques and it has had limited review in
ated cellulose to cause an increase in compound the literature. Orthodontic anchorage is first ob-
action potentials and decrease in nerve conduc- tained with banding of the first molars and a stain-
tion velocity at 1 hour, with full sensory recovery less steel lingual arch wire welded too it. The
by 4 weeks. They found a gelatin sponge to anchorage is further strengthened with a stainless
demonstrate an increased compound action po- steel sectional wire from second molar to first
tential at 4 weeks, although their sponge was bicuspid. Tooth angulation dictates bracket posi-
coated with silver potentially causing this effect. tion. Vertical or distal angulated teeth require
They cautioned against the use of bone wax bracket placement on the occlusal surface
because of case reports of chronic inflammation centered in an axial position. Mesially or horizon-
and embolization to the lungs. They concluded tally inclined teeth require bracketing on the distal
that bovine collagen was the safest agent in surface of the crown and possibly stripping of a
regards to adverse effects on neural function. portion of the crown. Regardless of impaction
Collagen conduits are a popular choice for nerve type, advanced imaging is necessary to appre-
entubulization techniques clinically. ciate vector of forces required to erupt the roots
Once hemostasis is obtained, a single suture away from the canal. After 1 week of soft tissue
should be placed for partial closure distal to the healing, a cantilever wire is placed off the buccal
second molar. A review of recent literature tube on the first molar to the bracket placed on
revealed this to be the best overall closure method the impacted third molar. This is then adjusted
in regards to edema and ease of application.25 every 4 to 6 weeks until the tooth is extruded. A
One must also be aware of proximity to the lingual panoramic radiograph is then taken once clinical
nerve and not take an excessive bite of lingual tis- extrusion has been confirmed. Standard third
sue to avoid incorporating the lingual nerve with molar impaction techniques can be used once
suturing, which can directly damage the nerve the risk of injury to the IAN is minimized.29
with the needle, and potentially compressing the Intraoperative techniques can be used to mini-
nerve after tie down of the suture.26 mize nerve injuries during placement of dental

Fig. 6. Intraoperative photographs of


the same patient in Figs. 1 and 2. On
the left note the exposure of the IAN
at the apex of #18 as predicted by CT
scan. The image to the right shows
allograft placed over gelatin sponge,
which was used as a protective barrier
of the IAN. The patient underwent a
short period of maxillomandibular
fixation and experienced no neuro-
sensory deficits postoperatively.
Trigeminal Nerve Injuries 417

implants in the mandible. This starts with local material. In an in vitro model, mineral trioxide aggre-
anesthesia techniques where some have advo- gate was found to be the only root end filling mate-
cated the use of infiltration versus a block, allowing rial that was incapable of inducing neurotoxicity
the patient to respond to pain if there is encroach- even while setting.34 Because of its favorable
ment on the nerve.30 If a flap is being reflected and biocompatibility it provides an excellent material
it is in the second molar region, the practitioner choice when the IAN is in close proximity. If guided
must be cognizant of the potential for proximity bone regeneration is planned and graft material is
to the lingual nerve.14 Careful retraction of the placed at the apex one must ensure it is not com-
flap in the mental nerve region and skeletonization pacted into the canal. Fig. 7 depicts intraoperative
of the nerve as it exits the mandible may also be photographs of the same patient in Fig. 5. The nerve
necessary to avoid traction injuries. During osteot- had presumably been damaged from aggressive
omy preparation, use of periapical radiographs curettage or rotary instrumentation at the time of
with marking pins has been shown to decrease injury. Foreign body was noted within the resultant
the chance of neurovascular encroachment, scar tissue and submitted to pathology.
particular in cases of marginal vertical height.31 Although no preoperative evaluation can avoid
Some also advocate the use of stoppers on os- local anesthetic-related nerve injury, injection
teotomy burs to avoid overpenetration.15 Osteot- technique can play a role. When performing
omy sites should be palpated with blunt probe to mental nerve or inferior alveolar nerve blocks, the
ensure there is no decortication of the nerve canal. surgeon should aspirate before injection. If a pa-
Surgical guides have been demonstrated to in- tient reports an immediate jolt or shock-like sensa-
crease accuracy, although these guides must be tion, the needle should also be withdrawn and
properly positioned to avoid inaccuracy when redirected to avoid intraneural injection. The event
transferring from the virtual plan to the patient. A should be documented in the chart to help differ-
2-mm safety zone should still be followed to allow entiate cause in the event a nerve injury occurs.32
for any potential inaccuracies. Thermal injury can The use of high-concentration local anesthetics
occur even without direct penetration because of should be avoided, and multiple blocks if at all
lack of appropriate irrigation or high-drill speeds. possible. In particular 4% prilocaine and 4% arti-
If graft materials are placed and there is decortica- caine are 7.3% and 3.6% more likely to cause
tion of the canal, this material may be mechanically paresthesia when used for IAN nerve blocks.35
pressed into the canal causing nerve injuries. Additionally, these agents have a higher chance
Finally, at the time of implant insertion, the implant of producing neuropathic pain compared with
must not be placed beyond the apical extent of the other commonly used local anesthetic agents.36
osteotomy by countersinking if the IAN is known to
be close apically.32 WHEN INJURY OCCURS
Apical surgery begins with review of existing
imaging. Landmarks should be identified to help Unfortunately, despite the best preparation and
guide the surgeon intraoperatively and maintain surgical techniques, injuries may still occur. Time
safe distances from the IAN and mental foramen.
Three incision designs can be used: (1) sulcular,
(2) papilla sparing, and (3) a semilunar flap.33 Typi-
cally releasing incisions are used with the first two
and these should be planned at least one tooth
anterior or posterior to the identified mental fora-
men. The dissection for all incisions should then
be subperiosteal and if near the mental nerve this
structure should be identified and protected to
avoid iatrogenic injury during instrumentation. Ac-
cess to the periapical lesion and root should be ob-
tained using anatomic references that were
selected before surgery. Caution must be exer-
cised when instrumenting the cavity being cogni-
zant of anatomic danger zones mentioned
previously. Once the periapical lesion has been Fig. 7. Damaged IAN nerve at apicoectomy site #19
removed, hemostasis is achieved using known he- shown in Fig. 5. The nerve appears to be damaged
mostatic agents.24 If the nerve is exposed, a resorb- from either rotary instrumentation or aggressive
able collagen barrier should be placed over the curettage. A foreign body was also noted within the
nerve to provide a barrier from the root end filling scar tissue and sent for pathologic examination.
418 Nizam II & Ziccardi

from injury dictates actions that can be taken. Wit- with a patient who returns with a postoperative
nessed or open injuries mandate immediate or de- neurosensory deficit.
layed early intervention depending on surgeon skill First and foremost, a baseline complete neuro-
level. If the patient is in the operating room and sensory examination is conducted and docu-
appropriate equipment is available, immediate mented in the chart. This begins with history and
repair may be attempted. If not, the ends of the a description of the sensory deficit or pain. It
nerve can be tagged with nonresorbable suture, must first be classified as painful or unpleasant
such as nylon or polypropylene, and the wound (dysesthesia) or absent, decreased, or altered
closed. Note is made of the site and type of injury (paresthesia, hypoesthesia, or anesthesia). Con-
and prompt referral can be made to a microneuro- stant pain is usually a result of a long-term injury
surgeon.26 Prior research has shown benefit to that has resulted from lack of afferent input from
anti-inflammatory medications following acute the periphery (differentiation) and is seen in
nerve injury, and consideration should be given patients with neuroma formation. If pain is intermit-
to a steroid, NSAIDs, or both.20 tent, one must determine if pain is stimulated or
Most nerve injuries, however, are not witnessed merely spontaneous and the length of each
and are noted at postoperative follow-up. The key episode. A visual analog scale is then used to
to ensuring the best overall patient outcome is quantify the pain on a scale of 1 to 10. The patient
identification of mechanism, appropriate neuro- should be questioned what if any pain medications
sensory testing, and timely surgical intervention if have been attempted and if so what their effects
necessary. An algorithm is provided in Fig. 8 that have been. If the patient’s complaint is caused
may provide guidance to the practitioner faced by decreased sensation it should be quantified

Fig. 8. Trigeminal nerve injury algorithm. NST, neurosensory testing.


Trigeminal Nerve Injuries 419

on a level of 1 to 10 and compared with the oppo- provide static light touch sensation. These fibers
site side. For either type of injury, interference with are evaluated by lightly touching the skin without
activates of daily living should be documented. Of indentation with the wooden end of a cotton
special note, if a lingual nerve injury has occurred, swab. If the patient cannot feel the contact, the
alteration of taste sensation (paraguesia) should pressure is then increased and the skin is lightly in-
be noted.26 dented. If this can be felt at the higher threshold it
After the chief complaint and symptoms have is recorded as felt, however, at a higher threshold.
been elucidated, attention is next directed at phys- If sensation is still not present even at the higher
ical examination. The patient should be seated threshold then this is recorded and the examiner
comfortably and all tests are administered with moves on to level C testing. Alternatively and
the patient’s eyes closed in a quiet environment. more accurately, Semmes-Weinstein filaments
The contralateral normal side is always tested first may be used. These are a graded set of filaments
to establish baselines. The examination starts with with increasing pressures required to deform each
mapping of the altered region. This can be done by filament. The filaments can be used in stepwise
using the wisp of a cotton-tip applicator in a brush fashion to accurately assess the patient’s
stroke fashion and having the patient raise his or threshold for detection.37,38
her hand when they no longer sense the cotton. Level C testing measures response to noxious
This is then marked and the process is repeated stimulus, which are carried by scantily myelinated
from different directions until the area is marked A delta fibers or nonmyelinated C fibers. Testing is
in its entirety. Photographic documentation can similar to level B in that initially light contact is
also be taken at this time. At this point, neurosen- made with a dental needle. If the patient does
sory testing differs if the patient suffers from anes- not feel this, contact is then made once again,
thesia/paresthesia versus dysesthesia.4 however this time slightly indenting the skin. If
If the patient has reduced or no sensation, levels the patient feels this it is recorded as an abnormal
of function are tested in a stepwise approach. response. If the patient does not feel this it is also
Level A testing evaluates larger-diameter A alpha recorded; however, further pressure need not be
and A beta fibers that are 5 to 12 mm in diameter. applied. Further testing by thermal means is not
This is performed implementing a cotton swab necessary; however, it may provide insight into
with the cotton drawn into a wisp. Testing is car- the exact damaged fibers. Ethyl chloride spray
ried out by applying 10 strokes on the normal provides cold stimulus and heat can be applied
side and the patient is asked to determine the di- with warmed gutta-percha or warm water dipped
rection of stroke for each. This process is then cotton-tip applicators. The results of these tests
repeated on the altered side and results are once are then recorded and the patient is diagnosed
again recorded by documenting how many out of as being normal, mildly impaired, moderately
the 10 attempts were correctly identified. A score impaired, severely impaired, or anesthetic. De-
of 9/10 or greater is considered normal. Two- grees of impairment can be ascertained from per-
point discrimination is then performed using a Bo- formance at each level of testing using Zuniga and
ley gauge or college pliers and a millimeter ruler. Essik’s algorithm seen in Fig. 9.4,37,39
The normal side is again tested first by starting If the patient suffers from dysesthesia, the three
with the calipers at zero and lightly touching the levels are again examined; however, in this context,
area. The patient is asked to identify if this feels all three levels are always examined regardless of
as one or two objects. The distance is then incre- outcome at any specific level. The goal of this ex-
mentally widened until the patient can discriminate amination is to identify the type of dysesthesia.
two separate points. After this the process is Starting with level A, testing is carried out as before
repeated on the side of pathology in similar by stroking the region with a cotton wisp. If the pa-
fashion. Within the inferior alveolar nerve and tient experiences pain that stops on removal of the
lingual nerve distributions the patient should wisp, this is termed allodynia or abnormal pain
have two-point discrimination of 4 mm and response to unpainful stimulus that ceases with
3 mm, respectively. Because there is a large vari- removal of stimulus. Level B is used to reveal if
ation from patient to patient, numbers should be the patient has hyperpathia, which is present if the
correlated to the contralateral nonpathologic patient has delayed-onset pain, increased intensity
side. If the patient has normal responses, the ex- on repeated stimuli, or pain that continues after the
amination need not continue. If abnormal re- stimulus ends. Level C testing tests for hyperalge-
sponses are recorded the examiner moves to sia. As before, a dental needle is used at a normal
level B testing.37 threshold to evoke pain and a slightly higher
Level B testing measures the smaller A beta fi- threshold if no reaction takes place. If the patient
bers of approximately 4- to 8-mm diameter, which has pain out of proportion to the examination on
420 Nizam II & Ziccardi

Fig. 9. Grading algorithm for evaluating trigeminal nerve injury by Zuniga and Essik. (From Lieblich SE. Endodon-
tic surgery. Dent Clin North Am 2012;56(1):121–32, viii–ix; with permission.)

the contralateral nonpathologic side this is consid- sprouting has occurred from adjacent nerves, or
ered hyperalgesia.37 there is a central mechanism to the pain. If, how-
Diagnostic nerve blocks may serve as a useful ever, the pain is relieved by diagnostic nerve
adjunct in localizing the lesion in a patient who is block, microsurgery may be indicated.4
dysesthetic. The blocks can be administered first After confirmation of nerve injury, classification,
more peripherally and then more centrally to help and documentation of injury, one may return to the
locate the lesion. Failure of the local anesthetic beginning of the algorithm in Fig. 8. The next step
block to eradicate symptomatology may indicate is to obtain imaging, which may start with a
that the nerve was not blocked, collateral macro panoramic radiograph to identify if any obvious
Trigeminal Nerve Injuries 421

pathology is evident. If suspicion exists and a for surgical intervention. If the patient has no return
possible mechanical injury is detected, advanced of sensation, minimal return that is not improving,
imaging, such as CBCT or traditional CT, may be or dysesthesia that is responsive to peripheral
obtained. If this confirms the suspicion and there blockade, a referral to a microneurosurgeon is pru-
is loss of continuity of the canal or encroachment dent at this time. Our own results have shown sta-
by foreign body, a referral should be made to a mi- tistically significant better sensory outcomes if
croneurosurgeon as soon as possible. If an repair is conducted before 6 months and in partic-
implant is encroaching on the canal this should ular for IAN injury. Additionally, it has been shown
be backed out or removed as soon as possible. that after 3 months, a complex array of central and
Fig. 10 shows the same patient with IAN injury peripheral changes that are unlikely to respond to
shown in Fig. 4 at time of surgery. Unfortunately, surgical manipulation may occur.42 This 3-month
the implants were not removed at time of identifi- referral decision point allows for examination, con-
cation of injury, relegating her to surgical explora- sent, and scheduling within 6 months by a micro-
tion and repair of the nerve. At this time no reliable neurosurgeon. If the patient is experiencing
method is available for lingual nerve imaging; how- continued improvement, the patient is then fol-
ever, with the advent of 3-T MRI, new imaging se- lowed on a monthly schedule and reassessed
quences, and advanced ultrasound, this may soon when no further improvement occurs or 12 months
be a possibility. have been reached. Conflicting data exist in re-
If no obvious pathology is noted, the patient gards to late repair of the IAN and lingual nerve.
should start a regimen of serial neurosensory Good outcomes have been noted in some studies
testing along with NSAIDS and possible consider- even after the 12-month mark, whereas others
ation for corticosteroids. An identical examination note drastic decreases in success.43,44 Because
should be performed at each appointment to allow conflicting evidence is present at this time, it
for comparison over time. Follow-up schedule seems prudent to respect wound healing physi-
should include examinations at 1 week, and 1, 2, ology and avoid the irreversible scaring that
and 3 months. Controversy still remains as to affects neural tracts by staging any delayed inter-
optimal time for surgical intervention. What is vention by no later than 1 year. Fig. 11 depicts a
known is that 75% of iatrogenic injuries to the third case of late repair. Large neuroma and scar tissue
division of the trigeminal nerve recover without formation is evident requiring resection of a large
intervention.40 Perhaps one of the best in vitro portion of the lingual nerve and subsequent cadav-
studies to date was performed by Jääskeläinen eric nerve graft (AxoGen, Alachua, FL).
and colleagues41 in 2004. They intraoperatively Dysesthesia that is unresponsive to peripheral
monitored 40 IAN nerves during bilateral sagittal nerve blocks is likely caused in part by central
split osteotomy (BSSO). They found that simple mechanisms, and surgical repair may not be indi-
demyelinating injuries recovered to baseline on cated (see Fig. 8). Benoliel and coworkers45
neurophysiologic testing within 3 months of injury. recently published a review article on this subject
For the reasons described previously, serial detailing terminology, mechanisms, and treat-
neurosensory testing is performed until the ment. They suggested the term painful traumatic
3-month point and a decision is made as to need trigeminal neuropathy to describe painful lesions

Fig. 10. This is the same patient in Fig. 3 who suffered bilateral IAN damage during implant placement. Unfor-
tunately the nerves were not decompressed immediately after identification of injury. (A) Right IAN after resec-
tion of nonviable segment and primary neurorrhaphy and before Axoguard (AxoGen, Alachua, FL)
entubulization. (B) The left IAN suffered less damage and required only external and internal decompression
on exploration.
422 Nizam II & Ziccardi

Fig. 11. (A) A late lingual nerve repair. Note a large neuroma and large amount of perineural scar tissue forma-
tion. (B) Because of the condition of the proximal and distal stump a large amount of nerve tissue was excised to
allow viable tissue neurorrhaphy. A cadaveric nerve graft (AxoGen) was placed. (C) The nerve graft was then sur-
rounded with a Neuragen collagen conduit (Integra Life Sciences) to protect from further perineural scar tissue
ingrowth.

postsurgically. Their evidence-based treatment al- norepinephrine receptor inhibitors (duloxetine)


gorithm is seen in Fig. 12. After someone has been versus gabapentin or pregabalin. Amitriptyline re-
diagnosed with painful traumatic trigeminal neu- mains the drug of choice; however, TCAs have
ropathy, a decision is made to start the patient multiple side effects because of their activity at
on tricyclic antidepressants (TCA) or selective multiple receptors (cholinergic, alpha, histamine,

Painful trauma c trigeminal


neuropathy (PTTN)

Amitriptyline Gabapen n

Nortriptyline/Duloxe ne Pregabalin

Gabapen n 1

Pregabalin

TCA/SNRI with
Gabapen n/Pregabalin 2

Opioids

Fig. 12. Stepped approach for treatment of painful traumatic trigeminal neuropathy. (1) If anticonvulsants fail
strong consideration should be given for combining a selective norepinephrine receptor inhibitor (SNRI). (2) If
this is contraindicated consideration should be given to opioids. TCA, tricyclic antidepressant. (From Zuniga JR,
LaBanc JP. Advances in microsurgical nerve repair. J Oral Maxillofac Surg 1993;51(1 Suppl 1):62–8; with
permission.)
Trigeminal Nerve Injuries 423

and so forth) and may be contraindicated or poorly panoramic images and computed tomography.
tolerated by patients. Selective norepinephrine re- J Oral Maxillofac Surg 2008;66(11):2308–13.
ceptor inhibitors address one of the TCA mecha- 8. Guerrero ME, Nackaerts O, Beinsberger J, et al.
nisms of action but have been found to be less Inferior alveolar nerve sensory disturbance after
effective. The newer antiepileptic drugs including impacted third molar evaluation using cone beam
gabapentin or pregabalin have a more benign computed tomography and panoramic radiography:
side effect profile and may be started in patients a pilot study. J Oral Maxillofac Surg 2012;70:
who refuse TCAs or have a contraindication. If 2264–70.
either class fails, then the other class is tried. If 9. Selvi F, Dodson TB, Nattestad A, et al. Factors that
this fails, then combination therapy is instituted are associated with injury to the inferior alveolar
with an agent from each class. If this again fails, nerve in high-risk patients after removal of third mo-
opioids may be considered. Unfortunately, even lars. Br J Oral Maxillofac Surg 2013;51(8):868–73.
with this stepped approach only 25% of patients 10. Susarla SM, Sidhu HK, Avery LL, et al. Does
experience 30% or greater improvement in symp- computed tomographic assessment of inferior alve-
toms.46 Of note, these drugs can be used in the olar canal cortical integrity predict nerve exposure
management of patients where surgery is indi- during third molar surgery? J Oral Maxillofac Surg
cated to help reduce further central and peripheral 2010;68(6):1296–303.
sensitization. 11. Umar G, Obisesan O, Bryant C, et al. Elimination of
permanent injuries to the inferior alveolar nerve
following surgical intervention of the “high risk” third
SUMMARY molar. Br J Oral Maxillofac Surg 2013;51(4):353–7.
12. Behnia H, Kheradvar A, Shahrokhi M. An anatomic
Iatrogenic injury to the trigeminal nerve can remain
study of the lingual nerve in the third molar region.
a source of concern and litigation even for the
J Oral Maxillofac Surg 2000;58(6):649–51 [discus-
most experienced oral and maxillofacial surgeons.
sion: 652–3].
This article provides the most up-to-date evi-
13. Miloro M, Halkias LE, Slone HW, et al. Assessment of
dence-based recommendations for identification,
the lingual nerve in the third molar region using mag-
prevention, and management of these injuries to
netic resonance imaging. J Oral Maxillofac Surg
provide the highest level of patient care. Through
1997;55(2):134–7.
this, the specialty can maintain excellence in den-
14. Benninger B, Kloenne J, Horn JL. Clinical anatomy
toalveolar surgery.
of the lingual nerve and identification with ultraso-
nography. Br J Oral Maxillofac Surg 2013;51(6):
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