Thetrigeminalnerve Injury: Arshad Kaleem,, Paul Amailuk,, Hisham Hatoum,, Ramzey Tursun
Thetrigeminalnerve Injury: Arshad Kaleem,, Paul Amailuk,, Hisham Hatoum,, Ramzey Tursun
Thetrigeminalnerve Injury: Arshad Kaleem,, Paul Amailuk,, Hisham Hatoum,, Ramzey Tursun
Injury
Arshad Kaleem, DMD, MDa, Paul Amailuk, BDS, FRACDS (OMS)b, Hisham Hatoum, DMD, MDa,
Ramzey Tursun, DDSa,*
KEYWORDS
Lingual nerve injury Inferior alveolar nerve injury Trigeminal nerve injury Microneurosurgery
KEY POINTS
The fifth cranial nerve is the largest cranial nerve and the largest peripheral sensory nerve in the hu-
man body.
As oral and maxillofacial surgery broadens in scope, the surgeon will increasingly be required to di-
agnose and grade trigeminal nerve injury accurately and in the case of some surgeons surgically
repair these injuries.
Injury to the branches of the trigeminal nerve is commonly associated with “negative” clinical symp-
toms of decrease in sensation (hypoesthesia, anesthesia), but may also be accompanied by dis-
tressing “positive” symptoms of prolonged or permanent painful or inappropriate sensation
(dysesthesia) and hypersensitivity (hyperesthesia).
The areas most often affected (upper and lower lips, maxilla, mandible, tongue, and chin) are impor-
tant in eating and touch and communication.
repair these injuries. In addition, litigation for iat- [these patients often suffer continuity loss of
rogenic damage to the trigeminal nerve is of one or more peripheral branches])
a
Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Miami, Deering Medical Plaza,
9380 Southwest 150th Street, Suite 170, Miami, FL 33176, USA; b Department of oral and maxillofacial surgery,
Gold Coast University Hospital, 1 hospital Boulevard, Queensland 4215, Australia
* Corresponding author.
E-mail address: [email protected]
Fig. 1. Resection of mandibular tumor including infe- Fig. 3. Implant placement within inferior alveolar
rior alveolar nerve. canal.
The Trigeminal Nerve Injury 3
Level C testing (noxious stimulus) Diagnostic nerve blocks can be performed at the
end of the examination. They are useful in patients
Fibers evaluated: Partial myelinated A-delta fi- who present with constant pain, or dysesthesia. A
bers and nonmyelinated C fibers. lack of response to the local anesthetic may indi-
Method: Lightly touch the skin with a dental cate a central mechanism to the pain or collateral
needle. If there is no response increase the macrosprouting from adjacent nerves.
pressure until light indentation of the skin. No clinical examination, however, is perfect. The
The temperature perception of hot and cold NST has been shown to exhibit high positive pre-
stimuli can also be tested with ethyl chloride dictive values (95%) and negative predictive
on a cotton tip or warm gutta-percha. values (100%) for LN injuries and moderate posi-
Hyperalgesia (abnormally increased sensi- tive predictive values (77%) and negative predic-
tivity to pain) is present if the patient has tive values (60%) for IAN injuries. This negative
pain out of all proportion in comparison with predictive value of 60% indicates that the NST
the normal side. may be less efficient at ruling out IAN injury. At
The Trigeminal Nerve Injury 5
Table 1
Medical Research Council Scale for grading sensory function of peripheral nerves as applied to the
trigeminal nerve
Grade Description
S0 No sensation
S1 Deep cutaneous pain in an autonomous zone
S2 Some superficial pain and touch sensation
S21 Pain and touch sensation with hyperesthesia
S3 Pain and touch sensation without hyperesthesia; static
2-point discrimination >15 mm
S31 Same as S3 with good stimulus localization and static 2-
point discrimination 7–15 mm
S4 Normal sensation
Table 2
Correlation of Seddon and Sunderland injury classification with site and severity of trigeminal nerve
injury
structures; that is, a more vigorous localized Magnetic resonance neurography (MRN) is an
crushing force. imaging technique that increases visualization of
3 .Neurotmesis: Total interruption of axonal con- peripheral nerves by suppressing the signal from
duction and supporting neural structures. adjacent tissue (primarily fat-containing struc-
tures, such as bone and muscle). The nerve signal
Sunderland divided these injuries into five types remains unsuppressed because the nerve con-
of increasing severity: tains little fat.14 Injuries to the trigeminal nerve
1 .Conduction block result in increased signal in T2 sequences at the
2 .Transection of the axon with intact site of injury.
endoneurium Furthermore, Zuniga’s findings suggest that
3 .Transection nerve fiber axons and sheath in- MRN can distinguish between different degrees
side intact perineurium of trigeminal neuropathy ranging from compres-
4 .Transection of the fascicles with nerve trunk sion/entrapment in nontraumatic causations to
continuity maintained only by epineural tissues compression/partial transection/transection and
5 .Transection of the entire nerve trunk neuroma formation commonly found in traumatic
injuries (Fig. 6). MRN can also demonstrate the
Meyer and Bagheri10 compared Seddon and normal IAN and LN anatomy, with a normal to in-
Sunderland’s classifications of peripheral nerve in- termediate signal thereby supporting the differen-
juries, concluding that Seddon’s classification was tial diagnosis of nonneural pain and sensory
most helpful to clinicians in making timely deci-
sions regarding surgical intervention. Jones13
also found that a neuropraxia often results in a re-
turn to sensation within the first 4 weeks, implying
an excellent prognosis. Late-onset of the return to
function indicates a more severe injury, such as
axonotmesis, and no return of sensation within
3 months means neurotmesis is likely. These find-
ings were grouped by Meyer and Bagheri into a ta-
ble that correlated clinical signs with anatomic
injury (Table 2).
disorder conditions. Based on Zuniga’s findings it Nguyen and colleagues6 found that in the setting
may be possible to correlate clinical findings, of an oral and maxillofacial surgery unit, with sur-
nerve injury classification, and surgical findings gery performed by trainees and specialist sur-
to a single imaging technique (Table 3). geons, risk factors for permanent IAN injury were
identifiable. These included increasing age
PREVENTION OF INJURY (25 years old), surgery performed by trainees,
surgery under general anesthesia, and mesioan-
In some cases, an insult to the trigeminal nerve gular impaction.
from surgery cannot be avoided, such as when Leung and Cheung15 identified specific risk fac-
resection of pathology involves branches of the tors for IAN and LN injury in third molar surgery, as
nerve (see Fig. 1). For dentoalveolar procedures, follows:
localization of the IAN by panoramic radiologic im-
aging or cone-beam computed tomography is Inferior alveolar nerve injury
essential. For all surgeries, the plan formulated Unerupted teeth (fully erupted 0.3%, partially
should involve the least amount of force, trauma, erupted 0.7%, unerupted 3%)15
and development of postoperative edema to be Radiographic signs (Panorex assessment)
placed on the neurovascular bundle. Diversion of IAN by root (30%)
Table 3
Correlation of MRN with trigeminal nerve injury classification, NST grading, and direct surgical
findings
Fig. 7. Surgical decision-making algorithm for the patient with traumatic trigeminal nerve injury. CR, close reduc-
tion; NSD, neurosensory reduction; NST, neurosensory testing; OR, open reduction. (Adapted from Bagheri SC,
Meyer RA, Khan HA, et al. Microsurgical repair of peripheral trigeminal nerve injuries from maxillofacial trauma.
J Oral Maxillofac Surg. 2009;67(9):1797; with permission.)
Fig. 8. Sagittal split osteotomy approach to inferior Fig. 9. Inferior alveolar nerve isolation after sagital
alveolar nerve. split ramus osteotomy.
The Trigeminal Nerve Injury 9
MANAGEMENT OF INJURY
Medical Management
In the setting of an acute injury, there is evidence
Fig. 10. Buccal cortical window to approach inferior that some benefit is derived from anti-
alveolar nerve. Intraoral approach.
inflammatory medication. This is at present pri-
marily based on experimental studies and the
Darkening of the root (11.4%) premise that ongoing neuroinflammatory pro-
Deflected root (4.6%) cesses can cause ongoing axonal damage.19
IAN exposure in surgery (unexposed 1.1%, Consideration should thus be given to adminis-
exposed 16.2%) tering steroids, nonsteroidal anti-inflammatory
Surgical approach (lingual split 5.7% > buccal drugs, or both where there are no other
approach 2.5% > coronectomy 0%) contraindications.
Surgeon experience (specialist 2.9% > trainee The patient with trigeminal nerve injury may later
1.3% > undergraduates 0.2%) experience dysesthesia resulting from either local
Which may well represent operations of or centrally driven mechanisms. Benoliel and co-
increasing risk being undertaken by more workers’20 review on this subject produced an
experienced clinicians evidence-based algorithm. Tricyclic antidepres-
sants, serotonin norepinephrine receptor inhibitors
(eg, duloxetine), and gabapentin or pregabalin all
Lingual nerve injury have a role. Their group found that amitriptyline
Unerupted teeth15 was the medication of choice but may not be ideal
Distoangular impactions (distal impaction in some patients because of poor tolerance of the
4% > horizontal impaction 2.8% > mesial side effects. However, these medications unfortu-
impaction 2.4% > vertical impaction 1.9%) nately only yielded benefits in 25% of patients,
Lingual flap retraction (3.1% vs no flap 3.1%) where 30% or greater symptom improvement
was the goal.21
Zuniga and Labanc22 suggested commencing
therapy with the anticonvulsants gabapentin or
pregabalin or combining these with tricyclic antide-
pressants/serotonin norepinephrine receptor in-
hibitors (amitriptyline, nortriptyline, duloxetine)
where there is a failure of initial response. In their
article, opioids are only considered when all other
medical options have failed. We recommend that
they only be used in the short term for acute injuries.
Surgical Management
When the nerve injury has occurred as a result of
trauma or ablative oncologic surgery, the nerve is
often visible and accessible in the surgical field.
An immediate repair is ideal in this case where
Fig. 11. Transcutaneous approach to inferior alveolar microsurgical expertise is available. Should the
nerve. surgical necessary knowledge be lacking, or
10 Kaleem et al
Fig. 12. Chronologic steps for microsurgical repair of trigeminal nerve. Surgical repair progresses from steps 1 to
3. Steps 4 and 5 are performed where tension-free coaptation is not possible or where there is no proximal nerve
limb. (Adapted from Bagheri SC, Meyer R. Microsurgical reconstruction of the trigeminal nerve. Oral Maxillofacial
Surg Clin N Am. 2013;25(2):292; with permission.)
conditions are unfavorable (a contaminated fascicles are either apposed passively in good
wound or patient who is medically unfit for further alignment and sutured within a conduit, or with
surgery), delayed primary repair within 1 week or an interpositional graft. Lack of tension is key for
secondary repair after granulation tissue has successful direct repair, with nerve stumps held
matured (1 month) are options (Fig. 7). together under tension tending to form scar tissue.
An unsuspected or unobserved nerve injury (the In addition, the repair must be protected from the
most common type in dentoalveolar mechanisms) potentially hostile wound bed.
benefits from surgical repair within 3 months of the
insult. The reconstruction is best performed under
general anesthetic with the use of an operating
microscope.
The infraorbital nerve is approached transcuta-
neously or transorally. The LN and IAN are
exposed transorally, through an sagital split ramus
osteotomy for the IAN (Figs. 8–10) or through a
submandibular skin incision (Fig. 11).
Surgical management in microneurosurgical op-
erations is performed in a stepped manner (Fig.
12). The nerve’s overlying bone, foreign bodies,
and surrounding scar tissue are removed. The
nerve is then carefully inspected, and neuromas
are removed. Where indicated, a small segment Fig. 13. Nerve protector around lingual nerve repair.
of the nerve is removed and the discontinuous Note the 1-mm gap between the proximal and distal
segments.
The Trigeminal Nerve Injury 11
Fig. 14. Comparison of direct repair with suture to repair with Axoguard implant. a Epineurium and connective
tissue have been removed for illustration purposes. (CopyrightÓ 2020 AxoGen. All rights reserved. Used with Ax-
oGen’s permission.)
The conduit and connector-assisted tension- repair of the peripheral nerve are as follows:
less microsurgical nerve coaptation is associ- external decompression (remove any tissue that
ated with less sensory disturbances when may be exerting pressure on the nerve), then inter-
compared with direct suture neurorrhaphy.23 nal neurolysis (removal of scar tissue or adhe-
When tensionless repair is not possible the sions). The surgeon should then prepare the
gap must be bridged with autograft, allograft, nerve stumps for repair by mobilizing proximal
or conduit (Axoguard, AxoGen).24 Safa and and distal nerve tissue and excising any scar tis-
Buncke’s25 review found that in gaps of less sue or neuromas. The nerve is then repaired by
than 6 mm, conduits consistently achieve func- coapting the segments without tension. Where
tional sensory recovery. Processed nerve allo- there is gap of greater than 3 to 6 mm and/or ten-
graft (eg, Avance, AxoGen) consistently sion in the closure then a graft should be consid-
achieves functional sensory recovery in gaps ered for a nerve gap reconstruction. Finally,
up to 70 mm. These allograft results are similar when there is proximal nerve limb available,
to autograft, but without the additional donor consider a nerve-sharing procedure from a suit-
site morbidity and surgical time. able local peripheral nerve (see Fig. 14). Postoper-
The current practice is to use conduits for atively dexamethasone and vitamin B complex
connector-assisted repair and as a nerve wrap should be used to aid in healing.
around the coaptation site (Fig. 13).23
The benefits of conduits are as follows: SUMMARY
Establishing a physical barrier between re- The branches of the trigeminal nerve are never far
paired nerve and physical environment. from the operating field of the oral and maxillofa-
Preventing aberrant axonal growth and cial surgeon. The surgeon will increasingly be
escape outside the nerve stumps. required to provide accurate diagnosis and
grading of trigeminal nerve injury, and surgical
Current research suggests that the conduit will management by oral and maxillofacial surgeons
contain the extracellular matrix proteins required will increasingly become common.
for optimal healing at the site of repair, optimizing Although trauma and ablative procedures for
the microenvironment for healing (Fig. 14). head and neck pathology can cause injuries, den-
Once surgery has been decided on and the sur- toalveolar surgical procedures remain an impor-
gical approach decided (transcutaneous vs tant cause of injury to the fifth cranial nerve, with
transoral), the chronologic steps in microsurgical the third division (V3) being the main branch
12 Kaleem et al
affected. All oral and maxillofacial surgeons should 6. Nguyen E, Grubor D, Chandu A. Risk factors for per-
be aware of strategies of avoiding iatrogenic injury, manent injury of inferior alveolar and lingual nerves
and know when referral and surgical management during third molar surgery. J Oral Maxillofac Surg
are appropriate. These injuries may cause signifi- 2014;72:2394–401.
cant functional deficits in patients, and litigation 7. M.A. Pogrel nerve damage in dentistry. Current ther-
is becoming more common. apy in oral and maxillofacial surgery. Chapter
The advent of new imaging techniques, such as 33,271-274.
MRN, promises a new paradigm where surgeons 8. Zuniga JR, Essick GK. A contemporary approach
can distinguish between different degrees of tri- to the clinical evaluation of trigeminal nerve in-
geminal neuropathy ranging from compression/ juries. Oral Maxillofacial Surg Clin N Am 1992;4:
entrapment in nontraumatic causations to 353–67.
compression/partial transection/transection and 9. Zuniga JR, Meyer RA, Gregg JM, et al. The accu-
neuroma formation commonly found in traumatic racy of clinical neurosensory testing for nerve
injuries. The surgeon is increasingly able to corre- injury diagnosis. J Oral Maxillofac Surg 1998;
late clinical testing with operative and radiologic 56(2).
findings. 10. Meyer R, Bagheri S. Microsurgical reconstruction of
Performing microneurosurgical repair in a step- the trigeminal nerve. Oral Maxillofacial Surg Clin N
ped manner is key in producing a successful and Am 2013;25:287–302.
predictable repair. The use of allogeneic nerve 11. Seddon HJ. Three types of nerve injury. Brain 1943;
grafts, conduits, and nerve protectors eliminates 6:237–88.
the morbidity of autogenous harvest and is associ- 12. Sunderland S. A classification of peripheral nerve in-
ated with less sensory disturbances post nerve juries producing loss of function. Brain 1951;74:
repair. 491–516.
Thanks to the efforts of numerous oral and 13. Jones RHB. Repair of the trigeminal nerve: a review.
maxillofacial surgeon and others in the health field, Aust Dent J 2010;55:112–9.
we are on the cusp of not only providing accurate 14. Zuniga J, Mistry C, Tikhonov I, et al. Magnetic reso-
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DISCLOSURE view of prospective studies. Int J Oral Maxillofac
Surg 2011;40(1).
R. Tursun and A. Kaleem are compensated
16. Behnia H, Kheradvar A, Sharokhi M. An anatomic
consultant for Axogen, Inc. P. Amailuk and H.
study of the lingual nerve in the third molar region.
Hatoum have nothing to disclose.
J Oral Maxillofac Surg 2000;58(6):649–51 [discus-
sion:652-3].
17. Susarla SM, Sidhu HK, Avery LL, et al. Does
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