SPRING WEBINAR WITH DR. BRUCE DONOFF

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EDIC is pleased to announce a webinar with Dr. R. Bruce Donoff, the Dean at Harvard Dental School. Dr. Donoff’s presentation will cover the risk factors for inferior alveolar and lingual nerve injury after third molar extraction, as well as the proper documentation and follow up of nerve injuries. Dr. Donoff will also discuss the potential for recovery from paresthesia after surgical intervention. The webinar will be held on May 10, 2011 at 7:00 PM.

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SPRING WEBINAR WITH DR. BRUCE DONOFF

  1. 1. Inferior Alveolar and Lingual Nerve Injuries Algorithms for Management
  2. 4. Scenarios of Nerve Injury Inferior Alveolar Nerve <ul><li>Odontectomy </li></ul><ul><li>Following injection </li></ul><ul><li>Following endodontics </li></ul><ul><li>Following implants </li></ul><ul><li>Following genioplasty with or without BSSO </li></ul>
  3. 5. Scenarios of Nerve Injury Lingual Nerve <ul><li>Odontectomy </li></ul><ul><li>Periodontal surgery </li></ul><ul><li>Following injection </li></ul><ul><li>Screws of BSSO fixation </li></ul>
  4. 6. Tests of Nerve Injury <ul><li>Mapping </li></ul><ul><li>Mapping with tactile, thermal and pulp stimulation </li></ul><ul><li>Serial tactile and thermal tests </li></ul><ul><li>Clinical test algorithms with tactile and painful stimuli </li></ul><ul><li>Somatosensory evoked potentials </li></ul><ul><li>Microelectroneurography </li></ul><ul><li>Electronic thermography </li></ul><ul><li>Taste with vital staining-videomicroscopy </li></ul><ul><li>Magnetic source imaging </li></ul>
  5. 10. The Five Radiographic Signs 1 Fig. 1: Darkening of the Root Fig. 2: Deflection of of the Roots Fig. 3: Interruption of White Line Fig. 4: Diversion of the IA Canal Fig. 5: Narrowing of the Root The Five Radiographic Signs 1 Fig. 1: Darkening of the Root Fig. 2: Deflection of the Roots Fig. 3: Interruption of White Line Fig. 4: Diversion of the IA Canal Fig. 5: Narrowing of the Root
  6. 11. Radiographic Risk Factors X-ray finding Sens (%) Spec (%) PPV (%) NPV (%) PPV (%) NPV (%) Diversion 50 82 34 89 2.7 99 Darkening 65 73 31 93 2.3 99 Interruption 80 54 25 93 1.7 99 Any finding 100 33 22 100 1.4 100
  7. 30. Case for Early Repair <ul><li>Animal studies – most support early repair, but some success late </li></ul><ul><li>Humans – difficulty comes from comparison of direct repairs vs. grafts, IAN and lingual nerve “lumping”, inconsistent indications and lack of randomized controlled trials for outcomes </li></ul>
  8. 31. Questions for treatment <ul><li>Frame the dilemma as an evidence-based question </li></ul><ul><li>Retrieve applicable, valid and current evidence to answer the question </li></ul><ul><li>Appraise the evidence for applicability and validity. What are the results? </li></ul>
  9. 32. Using Ultrasound to Visualize the Lingual Nerve Presented by James Olsen HSDM 2006 January 20, 2006 http://i.cnn.net/cnn/2003/HEALTH/08/27/ultra.stethoscope/story.portable.ultrasound.jpg
  10. 33. Mandibular Nerve Branches A. Auriculotemporal B. Lingual C. Inferior Alveolar D. N. to the Mylohyoid E. Mental F. Buccal http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/h_n/cn/cn1/images/cnb3.jpg
  11. 34. Lingual Nerve Anatomy The lingual nerve crosses the submandibular duct twice in the paralingual space. http://www.sciential.net/images/Clemente2f.jpg
  12. 35. Lingual Nerve Anatomy Pogrel MA, Renaut A, Schmidt B, Ammar A. The relationship of the lingual nerve to the mandibular third molar region: an anatomic study. J Oral Maxillofacial Surgery, 1995, pp. 1178-81.
  13. 36. Lingual Nerve Injury Loss of taste from anterior 2/3 of tongue ipsilateral to the lesion (special sensory component of CN VII) Loss of general sensation from the tongue (general sensory component of CN V3). http://info.med.yale.edu/caim/cnerves/cn7/cn7_graphics/fig7_25.gif
  14. 37. Treatment of Lingual Nerve Injuries Robinson PP, Alison RL, Julian MY, Smith KG. Current management of damage to the inferior alveolar and lingual nerves as a result of removal of third molars. British Journal of Oral and Maxillofacial Surgery , 2004; 42, 285-292
  15. 38. Case Report *Images courtesy of Dr. Donoff
  16. 39. Case Report
  17. 40. Imaging of Lingual Nerve Injuries CT
  18. 41. Imaging of Lingual Nerve Injuries Miloro M, Halkias LE, Slone HW, Chakeres DW. Assessment of the Linual Nerve in the Third Molar Region Using Magnetic Resonance Imaging. J Oral Maxillofacial Surgery , 1997; 55:134-137. MRI MRI
  19. 42. Using Ultrasound to Visualize the Lingual Nerve http://www.bbc.co.uk/health/images/300/ultrasound.jpg
  20. 43. Ultrasonography Altinok T, Baysal O, Karakas HM, Sigirci A, Alkan A, Kayhan A, Yologlu S. Ultrasonographic assessment of mild and moderate idiopathic carpal tunnel symdrome. Clinical Radiology, 2004 Oct; 59(10): 916-25
  21. 44. Ultrasonography De Kool BS, Van Neck JW, Blok JH, Walbeehm ET, Hekking IV, Gerhard H. Ultrasound imaging of the rabbit peroneal nerve. Journal of the Peripheral Nervous System , 10 (4), 369-374. PN, peroneal nerve; TN, tibial nerve; BF, biceps femoris muscle; SM, semimembranosus muscle; F, femur
  22. 45. Ultrasound <ul><li>A pulse is generated and transmitted from the transducer </li></ul><ul><ul><li>Frequency - number of repetitions per second (Hertz) </li></ul></ul><ul><ul><li>Wavelength - distance between excitations (0.1 – 1.5 mm) </li></ul></ul><ul><ul><ul><ul><ul><li>High frequency + short wavelength = Better resolution </li></ul></ul></ul></ul></ul><ul><ul><li>Amplitude - measured in decibels </li></ul></ul><ul><ul><li>Period - time necessary for one cycle to occur </li></ul></ul>(piezoelectric crystals)
  23. 46. Study HST transducer (25mm, 10-5 MHz). Sonosite 180 Plus
  24. 47. Study Yorkshire cadaver pig head OMFS Endoscopic Research Center
  25. 48. Study Surgery, Anesthesia, & Experimental Techniques in Swine by M. Michael Swindle, DVM
  26. 49. Study Yorkshire cadaver pig head
  27. 50. Study Yorkshire cadaver pig head
  28. 51. Study
  29. 52. Study
  30. 53. Study
  31. 54. Table 1: Summary Diagnostic Outcomes for Three Evaluators Average 17 / 27 (63%) Pig Key Evaluator #1 (Radiologist) Evaluator #2 (Senior Surgeon) Evaluator #3 (Surgical Fellow) 1 Right Partial Transection Intact Intact Partial Transection Left Nerve Intact Full Transection Intact Full Transection 2 Right Partial Transection Partial Transection Intact Full Transection Left Full Transection Full Transection Full Transection Intact 3 Right Nerve Intact Intact Intact Intact Left Partial Transection Partial Transection Partial Transection Partial Transection 4 Right Full Transection Full Transection Partial Transection Full Transection Left Nerve Intact Intact Intact Partial Transection 5 Right Full Transection Partial Transection Full Transection Full Transection Number of Correct Diagnoses (%) 6 (66.7%) 6 (66.7%) 5 (55.6%)
  32. 55. Results
  33. 56. Results
  34. 57. Table 2: Average distance of lingual nerve from alveolus as measured with ultrasound Pig Ave. distance from alveolus (mm) 1 Right 0.0 Left 1.867 2 Right 2.756 Left 0.533 3 Right 0.0 Left 1.956 4 Right 0.978 Left 0.356 5 Right 0.711 Average 1.02
  35. 58. Results Yorkshire cadaver pig head
  36. 59. Case Report *Images courtesy of Dr. Donoff
  37. 60. Discussion <ul><ul><li>It is in fact possible to see the lingual nerve with ultrasound </li></ul></ul><ul><ul><li>The result is near statistically significance – it is very likely that a larger sample size is needed to detect the difference as power may establish statistical significance for a relatively small effect size. </li></ul></ul><ul><ul><li>The pig nerve is closer to the alveolus than it is in the human </li></ul></ul><ul><ul><li>Pig nerve is roughly ¼ the size of the human nerve </li></ul></ul>
  38. 61. Conclusion <ul><ul><li>The results of this study show that ultrasonography can be used to visualize the lingual nerve.  Further studies and higher quality imaging are needed in order to determine the extent of involvement that ultrasound might have in both the prevention and surgical planning process of lingual nerve injuries. </li></ul></ul>
  39. 65. Susarla et al. JOMFS 65:1070, 2007
  40. 66. Susarla et al.JOMFS 65:1070, 2007
  41. 67. Susarla, et al. JOMFS 65:60, 2007
  42. 68. Susarla, et al. JOMFS 65:60, 2007
  43. 69. Hillerup and Stoltze. IJOMFS 36:1139, 2007
  44. 70. Hillerup and Stoltze IJOMFS 36: 1139, 2007
  45. 71. Hillerup and Stoltze IJOMFS 36:884, 2007
  46. 72. Hillerup and Stoltze IJOMFS 36:884, 2007
  47. 73. Caveats from Experience <ul><li>Lingual nerve injuries usually not painful </li></ul><ul><li>Trigger in LN injuries with anesthesia positive finding </li></ul><ul><li>IAN injuries often painful </li></ul><ul><li>Operated IAN injuries often develop pain syndromes </li></ul><ul><li>Age is a very important factor </li></ul><ul><li>Rare for anesthetic lingual nerve patients with Tinel’s like sign to recover </li></ul>

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