Thetrigeminalnerve Injury: Arshad Kaleem,, Paul Amailuk,, Hisham Hatoum,, Ramzey Tursun

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T h e Tr i g e m i n a l N e r v e

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.

INTRODUCTION increasing concern to oral and maxillofacial


surgeons.
The fifth cranial nerve is the largest cranial nerve Injury to the branches of the trigeminal nerve is
and the largest peripheral sensory nerve in the hu- commonly associated with “negative” clinical
man body. The importance of this primary somato- symptoms of decrease in sensation (hypoesthesia,
sensory cortex in daily function is well illustrated anesthesia), but may also be accompanied by dis-
by the trigeminal nerve representing close to half tressing “positive” symptoms of prolonged or per-
of the sensory area in the postcentral gyrus. Pa- manent painful or inappropriate sensation
tients with impaired function of the trigeminal (dysesthesia) and hypersensitivity (hyperesthesia).
nerve can present with significant functional defi- The areas most often affected (upper and lower
cits and a decreased quality of life.1 lips, maxilla, mandible, tongue, and chin) are
The trigeminal nerve is the primary sensory important in eating, touch, and communication.
neuron supplying the head and neck, and its
branches are never far from the operating field
of the oral and maxillofacial surgeon. As the spe- ETIOLOGY
cialty broadens in scope, the oral and maxillofa- Injuries to the trigeminal nerve are caused by:
cial surgeon will increasingly be required to
diagnose and grade trigeminal nerve injury accu- 1. Trauma (avulsive motor vehicle trauma, missile
rately and in the case of some surgeons surgically injuries, interpersonal violence, military combat
oralmaxsurgery.theclinics.com

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]

Oral Maxillofacial Surg Clin N Am - (2020) -–-


https://doi.org/10.1016/j.coms.2020.07.005
1042-3699/20/Ó 2020 Elsevier Inc. All rights reserved.
2 Kaleem et al

2. Ablative tumor operations in the oral and maxil-


lofacial region (Fig. 1)
3. Dentoalveolar surgical procedures2
 Removal of teeth (excluding third molars) and
cysts
 Nerve blocks
 Third molar removal
 Endodontic treatment (Fig. 2)
 Implant placement (Fig. 3)
In general, third molar removal had the highest
incidence of injury (40.8%), followed by endodon-
tic therapy (35.3%), other surgical procedures
(20.7%), and lastly implant placement (3.2%).
The data on injury to the first and second divi-
sion of the trigeminal nerve are sparse. Tay and
Zuniga in 20053 reported that the third molar was Fig. 2. Gutta-percha within inferior alveolar nerve as
the most common cause of referral for trigeminal result of endodontic injury.
nerve injury. Where third division injuries are con-
cerned, lingual nerve (LN) and inferior alveolar
nerve (IAN) injuries are the most common. Renton
and Yilmaz4 found that where IAN injury is con- Lost or altered sensation resulting from periph-
cerned third molar surgery is the most common eral trigeminal nerve injuries interferes with stan-
cause (60%), followed by local anesthetic injec- dard oral and facial functions and can result in a
tions (19%), implants (18%), and endodontic sur- significantly reduced quality of life for patients.1
gery (18%). Where LN injury is concerned, the This can mean the difference between an accept-
same authors found that in their population, third able return to function in the reconstructed tumor
molar removal was the leading cause (73%) fol- patient, detract from an otherwise successful
lowed by local anesthesia injections (17%). trauma repair, and present as unacceptable
Current literature accepts that the risk of injury morbidity in the elective wisdom tooth or implant
to either the IAN or LN occurs in 0.4% to 22% of patient. Thus, avoiding injury where possible, and
cases following third molar surgery.5 More offering a reconstruction of the trigeminal nerve
recently Nguyen and colleagues6 found the inci- where indicated, should be an integral part of the
dence of IAN injury as 0.68% and LN injury as surgical service provided to patients. This is of
0.15% in their study looking at 11,599 lower third particular importance in a clinical environment
molar extractions in 6803 patients. where more professionals are placing implants
Pogrel7 found that although the true incidence of
injury to the IAN from injection was unknown, he
estimated that permanent damage might occur
in 1 in 25,000 IAN blocks. He found most patients
entirely recovered with 85% recovering fully within
8 to 10 weeks, 5% taking longer, and 10% sustain-
ing permanent deficits.

Fig. 1. Resection of mandibular tumor including infe- Fig. 3. Implant placement within inferior alveolar
rior alveolar nerve. canal.
The Trigeminal Nerve Injury 3

and there is increased awareness of injuries by pa- Armamentarium


tients, and increased reporting of incidents by
professionals.  Cotton swab
 Boley gauge, or college pliers and a millimeter
rule or Axotouch (two-point discriminator [Ax-
PREOPERATIVE EVALUATION oGen, Alachua, FL]) (Fig. 5)
Patient History  Semmes-Weinstein filaments
A baseline complete neurosensory examination  Dental needle
consisting of a thorough history and physical  Ethyl chloride spray
should be conducted with care taken to document
the patient’s sensory deficit or pain accurately. Is Level A testing (light touch and direction
the patient experiencing “positive” symptoms, discrimination)
such as painful or unpleasant sensation (dysesthe-
sia)? Alternatively, are the symptoms more in the Fibers evaluated: Larger diameter A-alpha and
“negative” category with absent, decreased, or A-beta (5–12 mm diameter).
altered sensation (paresthesia, hypoesthesia, Method: The cotton fibers are drawn into a wisp,
anesthesia)? Is the pain constant (suggesting a and 10 strokes are applied with the patient
long-term injury or neuroma formation)? Is the being asked to determine the direction of the
pain intermittent? If so, are there instigating fac- strokes. Begin on the normal side and then
tors? Is it spontaneous and how long does each repeat on the altered side. Record how
episode last? Next, a visual analog scale should many attempts are correctly identified (9/10
be used to quantify the pain on a scale of 1 to is a normal score).
10. Determine further whether there are any Two-point discrimination is then performed us-
relieving or exacerbating factors. Have any medi- ing an Axotouch two-point discriminator, Bo-
cations or treatments been tried and have any suc- ley gauge, or college pliers and millimeter
ceeded? Lastly, establish from the patient what ruler. The patient is asked the smallest dis-
the effect of the injury is on their quality of life tance at which they can discriminate two
and activities of daily living. separate points (normal IAN distribution is
Thus, the patient can be placed in one of three 4 mm; normal LN is 3 mm).8 Compare the
groups based on whether they perceive a neuro- normal side with the altered side. Only if there
sensory or functional deficit from the injury, and are abnormal results does one proceed to
secondly, whether they are concerned about it or level B testing.
motivated to seek some intervention. Allodynia (abnormal pain response to a nonnox-
ious stimulus) is experienced as pain that
A. Not aware: does not care ceases with the removal of the stimulus.
B. Aware: does not care
C. Aware: cares
Level B testing (static and light touch)
The “aware and cares” patient is the one for
whom medical or surgical intervention is an abso-  Fibers evaluated: Smaller A-beta fibers (4–
lute requirement. 8 mm diameter).
 Method: Lightly touch the skin without inden-
tation using the wooden end of a cotton swab.
Physical Examination
If there is no response increase the pressure
The physical examination should take place in a until the skin is slightly indented. Start on the
quiet room with the patient relaxed, seated normal side and compare with the altered
comfortably, and with their eyes closed when tests side. Record whether light or heavy pressure
are administered. Clinical photography is instru- is required. More accuracy is obtained by us-
mental in mapping the affected areas and ing Semmes-Weinstein filaments in a step-
recording any trophic changes, or traumatic in- wise fashion, recording which filament is felt
juries and any obviously visible pathology. It is when it is deformed (increasing pressure is
good practice to begin the examination with the required to deform the larger filaments). If
“normal” side to establish a baseline. Any differ- the sensation is not present even at higher
ence in sensory testing is then graded using Zuni- pressures, then proceed to level C testing.
ga’s clinical Neurosensory Test (NST).8 If the  Hyperpathia (exaggerated response to a
patient has reduced or no sensation, then levels potentially noxious stimulus) is present if the
of function are tested in a stepwise approach patient has delayed-onset pain, or increasing
(Fig. 4). intensity on repeated stimuli.
4 Kaleem et al

Fig. 4. (A, B) NST used to grade tri-


geminal nerve injury. (From Bagheri
SC, Meyer R. Microsurgical recon-
struction of the trigeminal nerve.
Oral Maxillofacial Surg Clin N Am.
2013;25(2):289; with permission.)

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

 There may be inaccuracies in delineating the


anatomy and exact location of injuries.
 There may be underestimation or overestima-
tion of injuries, especially with variation in pa-
tient age, duration of injury, and cause of
injury.
The Medical Research Council Scale (MRCS)10
for sensory recovery is currently the reference
standard to identify functional sensory recovery af-
ter surgical repair (Table 1). The MRCS was origi-
nally developed in the United Kingdom to evaluate
sensory injuries in the upper extremity, but has
since been adapted for use in the head and neck
region. The patient is scored according to their
NST result with grades from S0 (no sensation) to
S4 (normal sensation). S3 is defined as “useful
sensory function” and S4 “complete sensory
Fig. 5. Axotouch, 2-point discriminator (AxoGen, Ala-
function.”
chua, FL). (CopyrightÓ 2020 AxoGen. All rights
reserved. Used with AxoGen’s permission.)
Classification of Nerve Injury Related to
Clinical Evaluation and Diagnosis
higher sensory impairment scores, the NST tends
to underestimate the degree of nerve injury for The date of the nerve injury incident and the prog-
IAN and LN. Conversely, at lower sensory impair- ress of symptoms are the features of clinical
ment scores, the NST tends to minimize the de- assessment used in the time-honored Seddon11
gree of damage.9 Besides, patients with different and Sunderland12 classifications, and the more
degrees of nerve injury may have similar NST recent Zuniga and Essick8 approach to the evalu-
scores, and there may be variation with age, dura- ation of these injuries.
tion, and cause of injury. Lastly, there may be Seddon’s classification is more than 75 years
added inaccuracy in examinations done less than old is but is still the most commonly used. He clas-
1-month postinjury. sified nerve damage into three categories:
Although clinically useful in providing diagnosis
and prognosis, as noted by Zuniga and col- 1 .Neuropraxia: Local conduction block with a
leagues,9 the NST has the following shortcomings: decrease in conduction; that is, retraction dur-
ing surgery or postoperative edema.
 There may be delays in treatment of higher 2 .Axonotmesis: The destruction of the axonal
class injuries that would have benefitted conduction and degeneration of the distal seg-
from earlier intervention. ments without disruption of the supporting

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

Grades S3, S31, and S4 are considered functional sensory recovery.


Adapted from Novak CB, Kelly L, Mackinnon SE. Sensory recovery after median nerve grafting. J Hand Surg Am.
1992;17(1):63; with permission.
6 Kaleem et al

Table 2
Correlation of Seddon and Sunderland injury classification with site and severity of trigeminal nerve
injury

Seddon Neuropraxia Axonotmesis Neurotmesis


Sunderland I II, III, IV V
Nerve sheath Intact Intact Interrupted
Axons Intact Some interrupted All interrupted
Wallerian degeneration None Yes, some distal axons Yes, all distal axons
Conduction failure Transitory Prolonged Permanent
Potential for spontaneous Complete Partial Little or none
recovery
Time to spontaneous Within 4 wk Begins at 5–12 wk, may None, if not begun
recovery take months by 12 wk
From Bagheri SC, Meyer R. Microsurgical reconstruction of the trigeminal nerve. Oral Maxillofacial Surg Clin N Am.
2013;25(2):90; with permission.

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).

Magnetic Resonance Neurography


Although they are standards of care at present, the
NST and MRCS rely on patient response to stim-
ulus and operator experience and may be inaccu-
rate in distinguishing levels of injury earlier than
1 month postinjury. The shortcomings of the NST Fig. 6. Scarring and neuroma of inferior alveolar
were described previously in this article. nerve.
The Trigeminal Nerve Injury 7

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

Clinical NST Level and


Sunderland MRCS Level Grade Surgical Findings by
Classification Description Direct Inspection MRN Finding
I Normal, S31 or S4 by Intact with no internal Anatomic,
3 mo of external fibrosis, homogenous, mild
normal mobility, and increased T2W nerve
neuroarchitecture signal
II Normal, S31 or S4 by Intact with no internal Anatomic homogenous,
6 mo of external fibrosis, increased T2W signal
restricted mobility, and mild nerve
but neuroarchitecture thickening or
intact constriction,
perineural fibrosis
III Mild or moderate injury, Intact with internal and Anatomic, homogenous
S21, S3 by 6 mo external fibrosis, increased T2W signal
restricted mobility, of nerve and
and disturbance of moderate thickening
neuroarchitecture or constriction,
(abnormal fascicle perineural fibrosis
patterns and/or
Fanconi bands not
visible)
IV Moderate or severe Partially transected Anatomic,
injury, S1, S2, S21 nerve, but some heterogenous T2W
by 6 mo amount of distal signal of nerve and
nerve present with or neuroma in
without neuroma in continuity, perineural
continuity and intraneural
fibrosis
V Severe or complete, S0, Completely transected Anatomic,
S1 by 6 mo nerve with or without discontinuous nerve
amputation neuroma with end bulb
neuroma

Abbreviation: T2W, T2-weighted.


From Zuniga J, Mistry C, Tikhonov I, et al. Magnetic resonance neurography of traumatic and nontraumatic peripheral
trigeminal neuropathies. J Oral Maxillofac Surg. 2018;76(4):727; with permission.
8 Kaleem et al

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

 Lingual split approach (lingual split


9.3% > buccal approach 2.3% > coronectomy
0.7%)
Surgeons should be cognizant of the variability
of the LN in relation to the area distal to the third
molar with the nerve lying at or above the lingual
alveolar crest in 10% of patients and in contact
with the lingual plate in 25% of cases in the third
molar region.16 Where the IAN or LN is exposed,
but not traumatized by the surgical procedure,17
surgeons should consider protecting the nerve.18

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
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