Nerve injuries /certified fixed orthodontic courses by Indian dental academy


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Nerve injuries /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. NERVE INJURIES   NERVE: Nerves are solid white cords made up of bundles of axons • Each nerve fiber is known as an axon • Each axon is bound by fibrous tissue into small bundles   The nerve trunk is composed of 4 connective tissue sheaths from outside inwards are:
  3. 3.   1.Mesoneurium: Suspends nerve within soft tissue and provides segmental blood supply to it. 2.Epineurium: Protects nerve from mechanical stress 3.Perineurium 4.Endoneurium • Group of nerve fibers- FASCICULI • Each FASCICULI is surrounded by PERINEURIUM • Group of FASCICULI forms a NERVE
  4. 4. Etiology of Nerve injuries: a. LOCAL CAUSES • Facial bone fractures. • Treatment of oral pathological conduction. • Maxillofical reconstructive surgery. • Removal of impacted lower third molar. b. CENTRAL DISEASES - Syringomyelia - Multiple Sclerosis - Bulbar Paralysis
  5. 5. Classification of Injuries: In 1943 SEDDON introduced a classification of nerve injury based on three types of nerve fiber injury. 1. Physiologic Disruption NEUROPRAXIA, 2. Axonal disruption AXONOTEMESIS, 3. Division of the nerve NEURONOTEMESIS.
  6. 6. Neuropraxia: 1. Least severe form of peripheral nerve injury, 2. Result of contusion of the nerve ( continuity of epineurial sheath and axons maintained. 3. Blunt trauma, traction stretching of nerve, inflammation or local ischemia 4. Full recovery of the nerve function within few days or weeks.
  7. 7. Axonotmesis: Blunt trauma, nerve crushing, extreme traction of nerve. • Afferent fibers degenerate but nerve trunk intact, no disruption of endo/peri/Epineurium • Recovery is good but incomplete (2, 4- 12month)
  8. 8. Tinnel’s sign: Painful, electric shock like sensation elicited by tapping directly over the cutaneous distribution of injured nerve
  9. 9. Neurotmesis: Severe disruption of connective tissue component of nerve trunk. ( Loss of nerve continuity) Prognosis for recovery poor Sensory recovery is not expected when nerve in soft tissue, but if within canal minimal recovery expected
  10. 10. SUNDERLAND (based on degree of tissue injury) Five degrees based on increasing anatomic severity of injury. Classification Description Grade I Loss of axonal conduction Grade II Loss of axonal Continuity Grade III Loss of axonal and endoneurial continuity Grade IV Loss of perineurial continuity with fascicular disruption Grade V Loss of continuity of entire nerve trunk
  11. 11. COMPARTMENT SYNDROME: •  Local increase in pressure (edema/venous stasis) causing decreased oxygenation. • Abnormal vibration and touch perception
  12. 12. TESTING FOR NERVE INJURY: 1. Light touch: cotton wisp 2. Two-point discrimination: >10mm abnormal 3. Localization 4. Sharp blunt differentiation 5. Thermal stimuli: 150 c to 500 c
  13. 13. BASIC PRINCIPLES OF NERVE REPAIR: 1. Decompression: 2. Neurorraphy: (Gap of 10mm only) a. Preparation of nerve stumps b. Approximation c. Cooptation e. Maintaining the cooptation  3. Nerve Grafts: - Sural nerve - Greater auricular nerve
  14. 14. TRIGEMINAL NEURALGIA Synonyms: ·       Tic douloureux- spasmodic contraction of facial muscles ·       Fother gill’s disease ·       Trifacial neuralgia
  15. 15. Definition: ‘A painful unilateral affliction of the face, characterized by brief electric shock like (lancinating) pain limited to the distribution of one or more divisions of the trigeminal nerve’
  16. 16. PREVIOUSLY CLASSIFIED AS: 1. Classical trigeminal neuralgia or Idiopathic trigeminal neuralgia 2. Specific trigeminal neuralgia (known etiology) Pre- trigeminal neuralgia (PTN
  17. 17. INCIDENCE:     Female affected more than males (3:2)    Right > left    Middle age and elderly   4% Bilateral    95% Maxilla + Mandibular nerve involved 5% Ophthalmic nerve involved
  18. 18. CLINICAL FEATURES: “WHITE AND SWEETS CRITERIA” 1. PAIN:  Paroxysmal (lasts from few seconds to few minutes)  Extremely intense (stabbing/ lightening/ pricking/ knife like) Pain free episodes/ intervals
  19. 19. 2. TRIGGER ZONES:         Vermilion/ alae/ cheeks/ periorbital area         Cutaneous in distribution         Stimuli includes- touch/ breeze/ talk/ chew/brush/shave 3. PRE-TRIGEMINAL NEURALGIA(PTN):       Mild, lancinating/pricking type Months to years before chronic type of trigeminal neuralgia 4. HYPERESTHESIA/ HEPERALGESIA On routine clinical examination
  20. 20. 5. ALWAYS UNILATERAL: If bilateral, then only one side affected at a time        Unshaven and unclean face (frozen face)        Spontaneous remission is unusual        Attacks do not occur during sleep(characteristic)        Secondary radiation of pain to adjacent division HYPOTHESIS: 1. Neural back talk theory – secondary to nerve injury 2. Deafferentation of central processes due to peripheral injury
  21. 21. CLINICAL FEATURES:       Male = female       Middle age or late life       Pain: lancinating pain of oropharynx or neck, lasts for week-months       Triggered by swallowing/ cough/ talk       Unilateral & radiates to ear & or mouth       Syncope is a feature       Rarely causes xerostomia/excess salivation       Disturbs sleep
  22. 22. ETIOLOGY: 1. C-P angle tumors: Acoustic Neuroma/ Cholesteotoma/ Meningioma/ Osteoma/ Angioma 2. Anatomical variation of Petrous bone/ridge 3. Aneurysms and Adhesions 4. Multiple Sclerosis INVESTIGATIONS: Nerve functions- sensory and motor (trigger zones) Diagnostic nerve blocks Special tests for tumors and systemic diseases
  23. 23. Treatment modalities: Medical: (A) 1. Phenytoin sodium (dilantin) 200-600mg/day in divided doses 2. Carbamazepine (tegretol/ carbital) Initially – 100mg BID       Increase to 200mg TID   3. Max. Dose is 1200mg/day in divided doses Baclofen or l-baclofen (lioresal) 10-80-mg/ day in divided doses 4. Valproic acid (depakote) 125-250 mg/day 5. Clonazepam (klonopin) 0.5 - 8mg/day 6. Pimiozide (orap) 2-12 mg/day 7. Lamotragine (lamicital) 50-100mg/day
  24. 24. (B) PERCUTANEOUS injections:(2days -1-week interval) Chemicals used: local anesthesia/ absolute alcohol/ phenol- glycerin mixture Injection site: peripheral nerves/trigger zones/gasserian ganglion (C) percutaneous electro-coagulation (D) cryosurgery (-900 to –1600 c) (E) ratners procedure/ osseous curettage Bone decortication+curettage+triple antibiotic pack (chloromphenicol+tetracycline+iodoform)
  25. 25. TREATMENT: ▪         Medical: - Carbamazepine/ Phenytoin/ Baclofen ▪         Local: - Cryotherapy/ Alcohol Injection ▪         Surgery: - Section GPN & Upper Rootlets Of Vagus ▪         Central: - Micro vascular Decompression
  26. 26. Thank you For more details please visit