Selva Arockiam, profile picture
Uploaded bySelva Arockiam
3,425 views

Nerve injuries during impaction surgeries

This document discusses nerve injuries that can occur during mandibular impaction surgeries such as the removal of lower third molar teeth. It provides classifications of nerve injuries including Seddon and Sunderland classifications. Mechanisms of nerve injuries include crush, stretch, laceration and ischemia. The document outlines techniques to prevent nerve injuries during surgery such as careful planning of incisions and use of imaging to identify nerves. It also discusses evaluating and managing nerve injuries post-operatively through neurosensory testing.

Health & Medicine◦
Related topics:
Oral Surgery•

Embed presentation

1 / 103
2 / 103
3 / 103
4 / 103
5 / 103
Most read
6 / 103
7 / 103
Most read
8 / 103
9 / 103
10 / 103
11 / 103
12 / 103
13 / 103
14 / 103
15 / 103
16 / 103
17 / 103
18 / 103
19 / 103
20 / 103
21 / 103
22 / 103
23 / 103
24 / 103
25 / 103
26 / 103
27 / 103
28 / 103
29 / 103
30 / 103
31 / 103
32 / 103
33 / 103
34 / 103
35 / 103
36 / 103
37 / 103
38 / 103
39 / 103
40 / 103
41 / 103
42 / 103
43 / 103
44 / 103
45 / 103
46 / 103
47 / 103
48 / 103
49 / 103
50 / 103
51 / 103
52 / 103
53 / 103
54 / 103
55 / 103
56 / 103
57 / 103
58 / 103
59 / 103
60 / 103
61 / 103
62 / 103
63 / 103
64 / 103
65 / 103
66 / 103
67 / 103
68 / 103
69 / 103
70 / 103
71 / 103
72 / 103
73 / 103
74 / 103
Most read
75 / 103
76 / 103
77 / 103
78 / 103
79 / 103
80 / 103
81 / 103
82 / 103
83 / 103
84 / 103
85 / 103
86 / 103
87 / 103
88 / 103
89 / 103
90 / 103
91 / 103
92 / 103
93 / 103
94 / 103
95 / 103
96 / 103
97 / 103
98 / 103
99 / 103
100 / 103
101 / 103
102 / 103
103 / 103
NERVE INJURIES DURING MANDIBULAR IMPACTION SURGERIES By A.Selva Arockiam, CRI
Procedures associated with peripheral trigeminal nerve injuries are listed in descending order of frequency, based on a survey (1981 to 2010) • Removal of lower third molar teeth • Orthognathic surgery • Maxillofacial trauma (fractures, soft tissue injury, gunshot wound) • Dental implants • Cyst or tumor excision • Preprosthetic surgery (vestibuloplasty, ridge augmentation) • Root canal treatment (canal filling, apical surgery) • Local anesthetic injection • Salivary gland excision • Biopsy DCNA MARCH 2011
Mechanisms of Injuries • Crush / compression • Stretch / traction • Laceration / transection • Metabolic disturbance • Ischaemia • Radiation • Electrical injury • Thermal injury
Classification of Nerve Injuries Seddon BMJ 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) • Localised degeneration of the myelin sheaths • Complete interruption of axons • Preservation of supporting structures (Schwann tubes, endoneurium, perineurium) • All essential parts destroyed • Interruption can occur without apparent loss of continuity
Classification of Nerve Injuries Neurapraxia Axonotmesis Neurotmesis Motor - - - Sensory +/- - - Autonomic +/- - - NCS Conduction block at the site Distal conduction preserved Loss of conduction both at and distal to the lesion Loss of conduction both at and distal to the lesion EMG No fibrillation Fibrillation ++ Fibrillation ++ Recovery Days to weeks provided the cause is removed Months provided the cause is removed No recovery unless repaired
Classification of Nerve Injuries Sunderland 1951 I II III IV V Focal conduction block NO Wallerian degeneration Axonal Disruption Axon + Endoneurium Disruption Axon + Endoneurium + Perineurium Disruption Axon + Endoneurium + Perineurium + Epineurium Disruption Cross-innervation
Physiological Conduction Block • Type A – Intraneural circulatory arrest – Metabolic block with no nerve fibre pathology – Immediately reversible • Type Bpe B – Intraneural oedema – Increased endoneurial fluid pressure – Reversible within days or weeks
Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal damage Axon + Endo damage Axon + Endo + Peri damage Axon + Endoneurium + Perineurium + Epineurium damage Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneurium + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Non- degenerative Degenerative
Classification of Nerve Injuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneurium + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
Anteromedial to inferior alveolar nerve
causes • The depth of impaction and the degree of imposition of the root structures over the inferior alveolar canal space . • surgical incisions placed too far lingually • breaching the lingual cortex with a surgical bur
• Other anatomic factors, such as lingual angulation of the third molar, • need for vertical sectioning
degree of angulation of impacted 3rd molar vs nerve injury 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 4.00% inferior alveolar nerve lingual nerve Int. j. Oral Maxillofacial.Surgery 2011 :40:1-10
Depth of impaction of mandibular 3rd molar and nerve injury 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% fully erupted partially erupted unerupted inferior alveolar lingual Int. j. Oral Maxillofacial.Surgery 2011 :40:1-10
Surgical techniques vs nerve injury 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% buccal approach lingual split coronectomy inferior alveolar lingual Int.J.Oral Maxillofacial surgery 2011:40:1-10
Intra-operative factors vs nerve injury 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% IAN exposed IAN not exposed inferior alveolar nerve inferior alveolar nerve Int. J.Oral Maxillofacial surgery 2011 : 40:1-10
Pathophysiologic response of a peripheral nerve to injury A normal myelinated axon associated with a longitudinal chain of Schwann cells and enclosed within a continuousbasal lamina. ( Courtesy of Don Johnson, Emory University, Atlanta, GA.)
Pathophysiologic response of a peripheral nerve to injury axonal degeneration,resulting in dissolution of distal myelin sheaths, degeneration of axoplasm distally, and sealing of the tip of the proximal stump of the axon. (Courtesy of Don Johnson, Emory University, Atlanta, GA.)
Pathophysiologic response of a peripheral nerve to injury The inflammatory response. The Schwann cell tube is invaded by macrophages that breach the basal lamina. Schwann cells distal to the injury site proliferate and axon sprouts begin to emerge from the proximal stump.
Pathophysiologic response of a peripheral nerve to injury Axonal regeneration: the proliferating Schwann cells form tube also known as the band of Bungner). Axon sprouts form from the proximal end of the axon. (Courtesy of Don Johnson, Emory University, Atlanta, GA.)
Pathophysiologic response of a peripheral nerve to injury Daughter Schwann Cells and complete regeneration in a less than critical nerve gap. Daughter Schwann cells remyelinate the regenerating axon.
Neuroma of the peripheral trigeminal nerve at its exit from the right mental foramen
• window of opportunity of approximately 6 months from the time of injury • Then success rates decline. • until a critical mass of distal nerve tissue is replaced by scar and is no longer capable of repair.
Preoperative radiologic risk assessment of the IAN and LN Panoramic Radiography • Routine preoperative assessment. • extremely limited due to the 2-dimensional nature of the image • the complete inability to visualize the position of the lingual nerve. • demonstrates the position of the inferior alveolar canal, and not the IAN, specifically.
Imaging Studies • Imaging studies are the basis for evaluation of contemplated M3 removal. • In addition to the depth of M3 within the mandible (soft tissue, partial bone, and complete bone impaction), and the angulation of the tooth within the alveolar bone (vertical, horizontal, mesioangular, distoangular), perhaps, the most important information is the position of the tooth roots in relation to the IAC.
• Four conditions can be identified: (1) superimposition, in which the roots and IAC are overlaid in the 2-dimensional radiograph but are actually not in physical contact or proximity; (2) notching of the root, in which the IAC is in intimate physical contact within an indentation in the side of the root; (3) grooving, in which the IAC is in intimate contact within a concave defect in the apex of the root; and (4) perforation, in which the IAC actually penetrates through the root .
• Conditions other than superimposition might require further evaluation with a computed tomographic scan .
Radiologic criteria indicating need for CT scan ADJ 2011(Kim ,et al.)
CBCT • inability to visualize the IAN itself (within the inferior alveolar canal), • or the LN, • because no accurate soft tissue information can be obtained with use of CBCT.
A B
C A)coronal, B) sagittal, C) axial. Images: adapted from (CBCT atlas (1918)).
Three-dimensional reformatted CBCT showing the course of the inferior alveolar canal between the impacted third molar roots.
High-Resolution Magnetic Resonance Imaging • Although detailed information can be obtained with the use MRI, routine presurgical evaluation of the route and integrity of the LN and IAN is not undertaken. • SUSPECTED CASES
Sagittal mandibular MRI image of a normal inferior alveolar nerve (arrows).
(B) HR-MRI image in the third molar region. Arrow indicates lingual nerve in direct contact with the lingual cortical plate.
Magnetic Resonance Neurography • distinguish nerves from surrounding structures such as blood vessels, lymph nodes, ligaments,adipose tissue, and ducts. • nerve continuity versus discontinuity at the fascicular level, and localize extraneural nerve compression prior to nerve exploration
Magnetic resonance neurogram
Sagittal T1 MRI images following third molar removal with intraventricular contrast injection to distinguish the inferior alveolar nerve (N) from the artery (A). There is evidence of signal increase in the IAN near the third molar extraction site ( E)
Ultrasonography • Relatively inexpensive imaging. • Radiationless imaging . • Minimally trained personnel. • not been employed or investigated as a potential preoperative risk assessment tool . • limitations :due to the presence of bone and teeth that might affect the echogenic signal.
Ultrasonography image of lingual nerve (upper arrow) above the lingual crest of the mandible (lower arrow).
PREVENTION OF NERVE INJURIES
1)Imaging guided operative procedure • Use of computed tomography to determine the exact location of M3 and IAC (arrows). • Multiple orientations (sagittal, axial, coronal) give exact information to assist the clinician in decisions regarding planning for partial or complete M3 removal.
Incision for exposure of M3 is placed in buccal gingival sulcus of erupted molars, then extended from the distobuccal corner of the last erupted molar lateroposteriorly to avoid intersection with the LN. A correctly placed soft tissue incision avoids trauma to the LN 2)Planning the incision
• Injury inevitable. • But significant sensory dysfunction of the LBN is extremely rare. (Henry 1996&Merrill 1979 LBN Nerve Jeoparadised
3)Soft Tissue Flap Retraction • Soft tissue flap retraction affords not only access to and visualization of the surgical field but also protection to important adjacent soft tissue structures, including the LN .
1)When removing bone to provide access to and exposure of M3, care Is taken to avoid penetrating the lingual alveolar bone. 2)If lingual bone must be removed to deliver the tooth, the lingual soft tissues (including LN) are protected with a suitable retractor .
M3 with enlarged follicular sac or early dentigerous cyst, which has eroded lingual alveolar bone. During removal of soft tissue surrounding M3 crown, surgeon inadvertently removed a portion of the adjacent LN . 4)Removing Soft Tissue Pathology
(A)When the M3 must be sectioned using a high-speed drill, carry the bur only three-fourth of the way through the tooth structure before separating the crown or the roots with an elevator. (B) The IAC (arrows) often lurks just beneath a deeply imbedded horizontally affected M3. 5)Sectioning Teeth
6)Partial Odontectomy • If the roots lie in intimate contact with the IAC, a partial odontectomy (coronectomy) should be considered. • The roots left in situ may remain in place and rarely, if ever, cause infection or other untoward incident . • In some cases, the roots migrate in a superior direction away from the IAC, allowing their subsequent removal to be nonproblematic.
(A)Preoperative view of distoangular M3 lying adjacent to IAC. (B)Immediate postoperative film showing removal of M3 crown; roots left in situ to avoid injury to IAN. (C) After 5 years, regeneration of bone and no reaction around retained M3 roots are noticed.
When closing the incision after M3 removal, look for LN before placing needle through lingual soft tissue flap. 7)Placing Sutures
Neurosensory testing • to grade the level of impairment of sensory function as • normal, or mild, moderate, or severe hypoesthesia, or complete (ie, anesthesia).
Nerve in Danger! Pain, Pain, Pain • Burning • Severe Autonomic dysfunction • Absence of sweating • Smoothness & dryness of skin Neurotrophic changes • edema • erythema • hypohydrosis • Hypokeratosis
Algorithm for neurosensory testing Patient c/o decreased altered sensation Level A (2-point discrimination, direction) Abnormal or absent responses Normal Level B (Contact detection) Increased threshold or no response Normal threshold (Mild hypoesthesia) Level C (Pain sensitivity) Normal threshold (Moderate hypoesthesia) Increased threshold (Severe hypoesthesia)
Directional discrimination (moving brush stroke direction identification): the thin black arrows indicate horizontal,vertical, or diagonal directions of the strokes that are applied randomly by the examiner. After each application, the patientis asked to duplicate the direction of the stroke with a cotton swab.
Level A testing for 2-point discrimination. (A) (Left) Measurement is begun by contact with the calipers closedtogether. (B) (Right) With each succeeding contact, the caliper beaks are separated by 1 additional millimeter until the patientindicates that 2 simultaneously applied contact points are felt (at 5 mm in this patient).
Level A testing for stimulus localization. (A) Five standard contact points (red dots) for stimulus localization. (B) The examiner contacts the patients skin lightly (no skin indentation) with a cotton swab at each contact point. After each contact by the examiner, the patient is asked to contact exactly the same point.
Semmes-Weinstein monofilament is an alternative method of evaluating static light touch (level B testing
Vitalometer readings of the lower teeth can be used as another method of level C testing for response to painful stimuli
Management of nerve injuries
George Bonney 1986
External decompression -Removal of surrounding bony, soft tissue structures and/or foreign material around the nerve
Internal neurolysis -Opening of the epineurium to inspect and decompress the nerve fascicles
Excision of neuroma - Removal of a neuroma associated with a nerve
Neurorrhaphy - Microsurgical anastamosis of a transected nerve
Prerequisites for Nerve Repair • Healthy tissue bed • Healthy nerve ends • No undue tension • Adequate soft tissue coverage • Minimal number of sutuers(Three to four sutures) .
Which of the following is false regarding fibrin glue? a) Fibrin glue is nontoxic and does not block axon regeneration b) It may be used in combination with suture repair c) The outcome of fibrin glue repair is inferior to that of suture repair d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength Tse & Ko. Nerve glue for peripheral nerve reconstruction. IOMFS journal 2012
Nerve Grafts/Conduits Autologous Source • Nerve autograft • Vein (+/- muscle) Off-the-shelf • Permanent nerve guidance conduit ( silicone) • Polyglycolic acid (PGA) • Caprolactone • Type I collagen Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. IOMFS JOURNAL2013
Nerve graft - Placement of a nerve graft (allogenic or autogenous) for nerve reconstruction
Principles of Nerve graft Transfers • Donor nerve near target motor end plates • Expendable donor nerve • Donor-recipient size match • Donor function synergy with recipient function • Sensory re-education improves function Mackinnon SE, Novak CB. BDJ 1999
(A) LN with a large neuroma (between the arrows) caused by of an impacted third molar removal. (B) The nerve has been repaired with a sural nerve graft (between the arrows) without any tension on the nerve segments
Intraoral exposure of the IAN with a neuroma in continuity secondary to M3 REMOVAL (B) Microsurgical repair using an autogenous nerve graft.
(A)Sural nerve graft harvest. (B) GAN harvest. (B)(C) Resulting area of anesthesia from a sural nerve harvest.
Greater auricular nerve harvested using a horizontal incision .
Guided nerve regeneration -Placement of a conduit to guide axonal sprouting and regeneration across a nerve gap from proximal to distal portions of a nerve
Gore-Tex conduit used for nerve reconstruction, demonstrating the distal repair
Neuro tube used as a nerve guide channel
(A) NeuraGen nerve guide can be used for nerve repair. (B) The NeuroGen tube has been used to repair the IAN.
(from Kim Y, Haftel VK, Kumar S, et al. The role of aligned polymer fiber-based constructs in the bridging of long peripheral nerve gaps. Biomaterials 2008;29:3117; )
Neurectomy- Microsurgical transection and removal of a segment of a peripheral nerve Nerve capping -Covering of the proximal stump of a transected nerve with its epineurium to prevent neuroma formation
Nerve redirection- Redirection of a nerve’s sensory innervation to a different anatomic location (usually adjacent muscle); usually done to prevent or minimize deafferentation
Prognostic Factors of Outcomes •AgePatient factor • Level of injury (distal vs proximal) • Type of nerve (pure vs mixed functions) • Condition of nerve ends Injury factors • Delay to repair • Length of gap Surgical factors
Postoperative rehabilitation for the patient any or all of the modalities listed • Physical therapy • Management of pain syndromes • Counseling, pyschiatric therapy, support group • Restoration of activities of daily living (work, spouse, recreation) • Sensory reeducation • Maintenance of supportive doctor-patient relationship
Summary • Proper pre-operative evaluation. • Proper planning of the operative procedure. Can be managed: • Institution of micro –surgical techniques at the right time . Can be avoided:

More Related Content

PPTX
Surgical Management of Jaw Tumors and Other Oral Cavity Tumors
byHermie Culeen Flores
 
PPTX
Inferior alveolar nerve injury
byJAMES RAJAN
 
PPTX
Treatment and complications of impactions
bySuparn Kelkar
 
PPTX
Facial neuropathology Maxillofacial Surgery
byLama K Banna
 
PPTX
TMJ Ankylosis.pptx
byRoyal Dental College Library
 
PPT
Pre-Prosthetic Surgery
byDr Bhavik Miyani
 
PPTX
Assessment of difficulty of mandibular impacted third molar
byDr. Preeti Satish
 
PPSX
Management of-extraction-complications
byWeam Faroun
 
Surgical Management of Jaw Tumors and Other Oral Cavity Tumors
byHermie Culeen Flores
 
Inferior alveolar nerve injury
byJAMES RAJAN
 
Treatment and complications of impactions
bySuparn Kelkar
 
Facial neuropathology Maxillofacial Surgery
byLama K Banna
 
TMJ Ankylosis.pptx
byRoyal Dental College Library
 
Pre-Prosthetic Surgery
byDr Bhavik Miyani
 
Assessment of difficulty of mandibular impacted third molar
byDr. Preeti Satish
 
Management of-extraction-complications
byWeam Faroun
 

What's hot

PPTX
Management of condylar fractures
bydralimohammedhasan
 
PDF
Wharfe2
byMahendra Perumal
 
PPTX
Nerve injuries seen in oral and maxillofacial surgery
byVinodThangaswamyS
 
PPTX
Mandibular fractures
byArjun Shenoy
 
PPTX
Management of cyst
byDr. swati sahu
 
PPT
Mandibular third moalr impaction
byAshish Soni
 
PPTX
Management of zygomatic complex fractures
byDr Shahzad Hussain
 
PPTX
Tmj surgical anatomy and approaches
byJoel D'silva
 
PPTX
Mandibular osteotomies in orthognathic surgery of Face
bySapna Vadera
 
PPTX
Impaction
byDental Library
 
PPTX
lab investigations in OMFS
bybhanupriya149
 
PPTX
Zygomatic Complex Fracture- ZMC
byHimanshu Soni
 
PPTX
Maxillary Osteotomy Procedures
bydr.nikil נαιη
 
PPTX
ZMC Fracture.pptx
byDentalYoutube
 
PPTX
Mandibular 3rd molar impactions
byMohammad Akheel
 
PPTX
Condylar fractures
byZeeshan Arif
 
PPTX
Zygomatic complex fractures
byMahak Ralli
 
PPTX
Finish lines (3) final
byms khatib
 
PDF
Endodontic surgery
byakhil shetty
 
PDF
Internal derangement of tmj
byDrKamini Dadsena
 
Management of condylar fractures
bydralimohammedhasan
 
Wharfe2
byMahendra Perumal
 
Nerve injuries seen in oral and maxillofacial surgery
byVinodThangaswamyS
 
Mandibular fractures
byArjun Shenoy
 
Management of cyst
byDr. swati sahu
 
Mandibular third moalr impaction
byAshish Soni
 
Management of zygomatic complex fractures
byDr Shahzad Hussain
 
Tmj surgical anatomy and approaches
byJoel D'silva
 
Mandibular osteotomies in orthognathic surgery of Face
bySapna Vadera
 
Impaction
byDental Library
 
lab investigations in OMFS
bybhanupriya149
 
Zygomatic Complex Fracture- ZMC
byHimanshu Soni
 
Maxillary Osteotomy Procedures
bydr.nikil נαιη
 
ZMC Fracture.pptx
byDentalYoutube
 
Mandibular 3rd molar impactions
byMohammad Akheel
 
Condylar fractures
byZeeshan Arif
 
Zygomatic complex fractures
byMahak Ralli
 
Finish lines (3) final
byms khatib
 
Endodontic surgery
byakhil shetty
 
Internal derangement of tmj
byDrKamini Dadsena
 

Similar to Nerve injuries during impaction surgeries

PPTX
Nerve affections following extractions of lower wisdom tooth
byAhmed Reda
 
PDF
Nerve Injuries After Third Molar Removal
byAndres Cardona
 
PPTX
Nerve Involvement in Oral Surgery
byHadi Munib
 
PDF
Nerve injuries
byFatemahIbrahim
 
PPTX
Nerve injury in dentistry
bySaya Aziz
 
PPTX
CLASSIFICATION OF NERVE INJURIES
byKeerat Kuckreja
 
PPTX
Nerve injury AR.pptx
byankitaraj63
 
PDF
Mandibular Third Molar And Inferior Dental Canal- A Tricky Situation
byQUESTJOURNAL
 
PDF
Australian dental j_97_-_ian_damage_following_removal_of_mandibular_3rd_molar...
bySaleh Alsadi
 
PPTX
SURGICAL ASPECTS OF MANDIBULAR AND MAXILLARY NERVE.pptx
byThoiSingh1
 
PPTX
SURGICAL ASPECTS OF MANDIBULAR AND MAXILLARY NERVE.pptx
byThoiSingh1
 
PPT
SPRING WEBINAR WITH DR. BRUCE DONOFF
byEastern Dentists Insurance Company
 
PPT
Trigeminal nerve
byHardik Vora
 
PPTX
Dental implant complications
bySwati Gupta
 
PPTX
Nerve injury
byCathrine Diana
 
PDF
12th publication - Dr Rahul VC Tiwari - Department of oral and Maxillofacial ...
byDr Rahul Vinay Chandra Tiwari
 
PDF
6th publication - IJADS - 1st name.pdf
byDr Rahul Vinay Chandra Tiwari
 
PPTX
Trigeminal nerve
bySheetal Kotni Patra
 
PPTX
IMPORTANT ANATOMICAL CONSIDERATIONS IN PERIODONTAL SURGERY AND IMPLANTS
byShrutiPatil123
 
PPTX
Maxillofacial nerve injury (trigeminal ).pptx
byDRMUSHTAQAHMAD5
 
Nerve affections following extractions of lower wisdom tooth
byAhmed Reda
 
Nerve Injuries After Third Molar Removal
byAndres Cardona
 
Nerve Involvement in Oral Surgery
byHadi Munib
 
Nerve injuries
byFatemahIbrahim
 
Nerve injury in dentistry
bySaya Aziz
 
CLASSIFICATION OF NERVE INJURIES
byKeerat Kuckreja
 
Nerve injury AR.pptx
byankitaraj63
 
Mandibular Third Molar And Inferior Dental Canal- A Tricky Situation
byQUESTJOURNAL
 
Australian dental j_97_-_ian_damage_following_removal_of_mandibular_3rd_molar...
bySaleh Alsadi
 
SURGICAL ASPECTS OF MANDIBULAR AND MAXILLARY NERVE.pptx
byThoiSingh1
 
SURGICAL ASPECTS OF MANDIBULAR AND MAXILLARY NERVE.pptx
byThoiSingh1
 
SPRING WEBINAR WITH DR. BRUCE DONOFF
byEastern Dentists Insurance Company
 
Trigeminal nerve
byHardik Vora
 
Dental implant complications
bySwati Gupta
 
Nerve injury
byCathrine Diana
 
12th publication - Dr Rahul VC Tiwari - Department of oral and Maxillofacial ...
byDr Rahul Vinay Chandra Tiwari
 
6th publication - IJADS - 1st name.pdf
byDr Rahul Vinay Chandra Tiwari
 
Trigeminal nerve
bySheetal Kotni Patra
 
IMPORTANT ANATOMICAL CONSIDERATIONS IN PERIODONTAL SURGERY AND IMPLANTS
byShrutiPatil123
 
Maxillofacial nerve injury (trigeminal ).pptx
byDRMUSHTAQAHMAD5
 

More from Selva Arockiam

PPT
Fluid control and_tissue_management
bySelva Arockiam
 
PPT
Bone graft
bySelva Arockiam
 
DOCX
Revised saliva as a diagnostic tool
bySelva Arockiam
 
PPTX
Ultrasonography
bySelva Arockiam
 
PPTX
Sialography
bySelva Arockiam
 
PPTX
Multilocular radiolucencies modified1
bySelva Arockiam
 
PPTX
Multilocular radiolucencies
bySelva Arockiam
 
PPT
Class i cavity prep1
bySelva Arockiam
 
PPTX
Pit and fissure
bySelva Arockiam
 
PPT
Csf & ventricles
bySelva Arockiam
 
PPT
Dental emergencies1
bySelva Arockiam
 
PPT
Dental emergencies1
bySelva Arockiam
 
PPT
ENDODONTIC EMERGENCIES
bySelva Arockiam
 
Fluid control and_tissue_management
bySelva Arockiam
 
Bone graft
bySelva Arockiam
 
Revised saliva as a diagnostic tool
bySelva Arockiam
 
Ultrasonography
bySelva Arockiam
 
Sialography
bySelva Arockiam
 
Multilocular radiolucencies modified1
bySelva Arockiam
 
Multilocular radiolucencies
bySelva Arockiam
 
Class i cavity prep1
bySelva Arockiam
 
Pit and fissure
bySelva Arockiam
 
Csf & ventricles
bySelva Arockiam
 
Dental emergencies1
bySelva Arockiam
 
Dental emergencies1
bySelva Arockiam
 
ENDODONTIC EMERGENCIES
bySelva Arockiam
 

Recently uploaded

PPTX
Methods of analysis for beer and vinegar.pptx
byRutvik Parikh
 
PPTX
Easy Peasy Gut: Complete Digestive Support
byEthniq
 
PPTX
DISORDERS OF PERCEPTION DETAILED FOR STUDENTS..pptx
byDr.Prakashkumar More
 
PPTX
Drug use evaluation and WHO drug use Indicators.pptx
byLok Raj Pant
 
PPTX
ppt on Cholangiocarcinoma.pptx BY DR MULATU ASFAW D GENERAL SURGEON
byDrmulatuasfaw
 
PPTX
Anaesthesia in Hypertension (anaesthesia in intercurrent diseases)
byajoseiyanu4
 
PPTX
BILIARY TREE RADIOLOGY ADVANCE IMAGING (USG, CT SCAN, MRI AND ERCP) OF ITS AN...
byjuryshira
 
PPTX
ppt on Cholangiocarcinoma.pptx PPT ON CHOLANGIOCARCINOMA EIOLOGY DIAGNOSIS AN...
byDrmulatuasfaw
 
PDF
Key Steps to Success With CDK4/6 Inhibition in Early Through Metastatic Breas...
byPVI, PeerView Institute for Medical Education
 
PDF
Retinoscopy & It's Principle - static vs dynamic retinoscopy in detail
bySamikshaRai22
 
PDF
Pediatric neurodegenerative disorders and anesthesia considerations. Dalamagk...
bycatlist1
 
PPTX
Biotransformation and Excretion
byBadrinathSelvakumar
 
PPTX
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
PPTX
Malignant focal liver lesions: A Radiologist's Perspective
byDr. Aryan (Anish Dhakal)
 
PDF
Echocardiography Oct. 15 2023 by Ichilov Hospital
byHaim R. Branisteanu
 
PDF
From Classification to Collaboration: Applying the International Classificati...
byOlaf Kraus de Camargo
 
PDF
Gastrointestinal Infection PCR Panel Diagnostic Screen
byFelixRendon3
 
PPTX
Human Excretory System (RIT): Kidney Functions & Urine Formation Made Easy
byBALAJI SOMA
 
PPTX
Chemistry of Hemoglobin (Types, Derivatives and Disorders)
byDr. Santhosh Kumar. N
 
PPTX
Neonatal Perioperative Care Pediatric Surgeons Perspective.pptx
byFaheem Andrabi
 
Methods of analysis for beer and vinegar.pptx
byRutvik Parikh
 
Easy Peasy Gut: Complete Digestive Support
byEthniq
 
DISORDERS OF PERCEPTION DETAILED FOR STUDENTS..pptx
byDr.Prakashkumar More
 
Drug use evaluation and WHO drug use Indicators.pptx
byLok Raj Pant
 
ppt on Cholangiocarcinoma.pptx BY DR MULATU ASFAW D GENERAL SURGEON
byDrmulatuasfaw
 
Anaesthesia in Hypertension (anaesthesia in intercurrent diseases)
byajoseiyanu4
 
BILIARY TREE RADIOLOGY ADVANCE IMAGING (USG, CT SCAN, MRI AND ERCP) OF ITS AN...
byjuryshira
 
ppt on Cholangiocarcinoma.pptx PPT ON CHOLANGIOCARCINOMA EIOLOGY DIAGNOSIS AN...
byDrmulatuasfaw
 
Key Steps to Success With CDK4/6 Inhibition in Early Through Metastatic Breas...
byPVI, PeerView Institute for Medical Education
 
Retinoscopy & It's Principle - static vs dynamic retinoscopy in detail
bySamikshaRai22
 
Pediatric neurodegenerative disorders and anesthesia considerations. Dalamagk...
bycatlist1
 
Biotransformation and Excretion
byBadrinathSelvakumar
 
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
Malignant focal liver lesions: A Radiologist's Perspective
byDr. Aryan (Anish Dhakal)
 
Echocardiography Oct. 15 2023 by Ichilov Hospital
byHaim R. Branisteanu
 
From Classification to Collaboration: Applying the International Classificati...
byOlaf Kraus de Camargo
 
Gastrointestinal Infection PCR Panel Diagnostic Screen
byFelixRendon3
 
Human Excretory System (RIT): Kidney Functions & Urine Formation Made Easy
byBALAJI SOMA
 
Chemistry of Hemoglobin (Types, Derivatives and Disorders)
byDr. Santhosh Kumar. N
 
Neonatal Perioperative Care Pediatric Surgeons Perspective.pptx
byFaheem Andrabi
 

Nerve injuries during impaction surgeries

  • 1.
    NERVE INJURIES DURING MANDIBULARIMPACTION SURGERIES By A.Selva Arockiam, CRI
  • 2.
    Procedures associated withperipheral trigeminal nerve injuries are listed in descending order of frequency, based on a survey (1981 to 2010) • Removal of lower third molar teeth • Orthognathic surgery • Maxillofacial trauma (fractures, soft tissue injury, gunshot wound) • Dental implants • Cyst or tumor excision • Preprosthetic surgery (vestibuloplasty, ridge augmentation) • Root canal treatment (canal filling, apical surgery) • Local anesthetic injection • Salivary gland excision • Biopsy DCNA MARCH 2011
  • 3.
    Mechanisms of Injuries •Crush / compression • Stretch / traction • Laceration / transection • Metabolic disturbance • Ischaemia • Radiation • Electrical injury • Thermal injury
  • 4.
    Classification of NerveInjuries Seddon BMJ 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) • Localised degeneration of the myelin sheaths • Complete interruption of axons • Preservation of supporting structures (Schwann tubes, endoneurium, perineurium) • All essential parts destroyed • Interruption can occur without apparent loss of continuity
  • 5.
    Classification of NerveInjuries Neurapraxia Axonotmesis Neurotmesis Motor - - - Sensory +/- - - Autonomic +/- - - NCS Conduction block at the site Distal conduction preserved Loss of conduction both at and distal to the lesion Loss of conduction both at and distal to the lesion EMG No fibrillation Fibrillation ++ Fibrillation ++ Recovery Days to weeks provided the cause is removed Months provided the cause is removed No recovery unless repaired
  • 6.
    Classification of NerveInjuries Sunderland 1951 I II III IV V Focal conduction block NO Wallerian degeneration Axonal Disruption Axon + Endoneurium Disruption Axon + Endoneurium + Perineurium Disruption Axon + Endoneurium + Perineurium + Epineurium Disruption Cross-innervation
  • 8.
    Physiological Conduction Block •Type A – Intraneural circulatory arrest – Metabolic block with no nerve fibre pathology – Immediately reversible • Type Bpe B – Intraneural oedema – Increased endoneurial fluid pressure – Reversible within days or weeks
  • 9.
    Classification of NerveInjuries Lundborg 1988 Physiological conduction block Myelin damage Axonal damage Axon + Endo damage Axon + Endo + Peri damage Axon + Endoneurium + Perineurium + Epineurium damage Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
  • 10.
    Classification of NerveInjuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneurium + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve) Non- degenerative Degenerative
  • 11.
    Classification of NerveInjuries Lundborg 1988 Physiological conduction block Myelin damage Axonal disruption Axon + Endo Axon + Endo + Peri Axon + Endoneurium + Perineurium + Epineurium Type A Type B Sunder land 1951 I II III IV V Seddon 1942 Neurapraxia (Transient Block) Axonotmesis (Lesion in Continuity) Neurotmesis (Division of a nerve)
  • 12.
  • 15.
    causes • The depthof impaction and the degree of imposition of the root structures over the inferior alveolar canal space . • surgical incisions placed too far lingually • breaching the lingual cortex with a surgical bur
  • 16.
    • Other anatomicfactors, such as lingual angulation of the third molar, • need for vertical sectioning
  • 17.
    degree of angulationof impacted 3rd molar vs nerve injury 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 4.00% inferior alveolar nerve lingual nerve Int. j. Oral Maxillofacial.Surgery 2011 :40:1-10
  • 18.
    Depth of impactionof mandibular 3rd molar and nerve injury 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% fully erupted partially erupted unerupted inferior alveolar lingual Int. j. Oral Maxillofacial.Surgery 2011 :40:1-10
  • 19.
    Surgical techniques vsnerve injury 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% buccal approach lingual split coronectomy inferior alveolar lingual Int.J.Oral Maxillofacial surgery 2011:40:1-10
  • 20.
    Intra-operative factors vsnerve injury 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% IAN exposed IAN not exposed inferior alveolar nerve inferior alveolar nerve Int. J.Oral Maxillofacial surgery 2011 : 40:1-10
  • 21.
    Pathophysiologic response ofa peripheral nerve to injury A normal myelinated axon associated with a longitudinal chain of Schwann cells and enclosed within a continuousbasal lamina. ( Courtesy of Don Johnson, Emory University, Atlanta, GA.)
  • 22.
    Pathophysiologic response ofa peripheral nerve to injury axonal degeneration,resulting in dissolution of distal myelin sheaths, degeneration of axoplasm distally, and sealing of the tip of the proximal stump of the axon. (Courtesy of Don Johnson, Emory University, Atlanta, GA.)
  • 23.
    Pathophysiologic response ofa peripheral nerve to injury The inflammatory response. The Schwann cell tube is invaded by macrophages that breach the basal lamina. Schwann cells distal to the injury site proliferate and axon sprouts begin to emerge from the proximal stump.
  • 24.
    Pathophysiologic response ofa peripheral nerve to injury Axonal regeneration: the proliferating Schwann cells form tube also known as the band of Bungner). Axon sprouts form from the proximal end of the axon. (Courtesy of Don Johnson, Emory University, Atlanta, GA.)
  • 25.
    Pathophysiologic response ofa peripheral nerve to injury Daughter Schwann Cells and complete regeneration in a less than critical nerve gap. Daughter Schwann cells remyelinate the regenerating axon.
  • 26.
    Neuroma of theperipheral trigeminal nerve at its exit from the right mental foramen
  • 27.
    • window ofopportunity of approximately 6 months from the time of injury • Then success rates decline. • until a critical mass of distal nerve tissue is replaced by scar and is no longer capable of repair.
  • 28.
    Preoperative radiologic risk assessmentof the IAN and LN Panoramic Radiography • Routine preoperative assessment. • extremely limited due to the 2-dimensional nature of the image • the complete inability to visualize the position of the lingual nerve. • demonstrates the position of the inferior alveolar canal, and not the IAN, specifically.
  • 29.
    Imaging Studies • Imagingstudies are the basis for evaluation of contemplated M3 removal. • In addition to the depth of M3 within the mandible (soft tissue, partial bone, and complete bone impaction), and the angulation of the tooth within the alveolar bone (vertical, horizontal, mesioangular, distoangular), perhaps, the most important information is the position of the tooth roots in relation to the IAC.
  • 30.
    • Four conditionscan be identified: (1) superimposition, in which the roots and IAC are overlaid in the 2-dimensional radiograph but are actually not in physical contact or proximity; (2) notching of the root, in which the IAC is in intimate physical contact within an indentation in the side of the root; (3) grooving, in which the IAC is in intimate contact within a concave defect in the apex of the root; and (4) perforation, in which the IAC actually penetrates through the root .
  • 32.
    • Conditions otherthan superimposition might require further evaluation with a computed tomographic scan .
  • 33.
    Radiologic criteria indicatingneed for CT scan ADJ 2011(Kim ,et al.)
  • 34.
    CBCT • inability tovisualize the IAN itself (within the inferior alveolar canal), • or the LN, • because no accurate soft tissue information can be obtained with use of CBCT.
  • 35.
  • 36.
    C A)coronal, B) sagittal,C) axial. Images: adapted from (CBCT atlas (1918)).
  • 42.
    Three-dimensional reformatted CBCTshowing the course of the inferior alveolar canal between the impacted third molar roots.
  • 43.
    High-Resolution Magnetic Resonance Imaging •Although detailed information can be obtained with the use MRI, routine presurgical evaluation of the route and integrity of the LN and IAN is not undertaken. • SUSPECTED CASES
  • 44.
    Sagittal mandibular MRIimage of a normal inferior alveolar nerve (arrows).
  • 45.
    (B) HR-MRI imagein the third molar region. Arrow indicates lingual nerve in direct contact with the lingual cortical plate.
  • 46.
    Magnetic Resonance Neurography •distinguish nerves from surrounding structures such as blood vessels, lymph nodes, ligaments,adipose tissue, and ducts. • nerve continuity versus discontinuity at the fascicular level, and localize extraneural nerve compression prior to nerve exploration
  • 47.
  • 48.
    Sagittal T1 MRIimages following third molar removal with intraventricular contrast injection to distinguish the inferior alveolar nerve (N) from the artery (A). There is evidence of signal increase in the IAN near the third molar extraction site ( E)
  • 49.
    Ultrasonography • Relatively inexpensiveimaging. • Radiationless imaging . • Minimally trained personnel. • not been employed or investigated as a potential preoperative risk assessment tool . • limitations :due to the presence of bone and teeth that might affect the echogenic signal.
  • 50.
    Ultrasonography image oflingual nerve (upper arrow) above the lingual crest of the mandible (lower arrow).
  • 51.
  • 52.
    1)Imaging guided operativeprocedure • Use of computed tomography to determine the exact location of M3 and IAC (arrows). • Multiple orientations (sagittal, axial, coronal) give exact information to assist the clinician in decisions regarding planning for partial or complete M3 removal.
  • 54.
    Incision for exposureof M3 is placed in buccal gingival sulcus of erupted molars, then extended from the distobuccal corner of the last erupted molar lateroposteriorly to avoid intersection with the LN. A correctly placed soft tissue incision avoids trauma to the LN 2)Planning the incision
  • 55.
    • Injury inevitable. •But significant sensory dysfunction of the LBN is extremely rare. (Henry 1996&Merrill 1979 LBN Nerve Jeoparadised
  • 56.
    3)Soft Tissue FlapRetraction • Soft tissue flap retraction affords not only access to and visualization of the surgical field but also protection to important adjacent soft tissue structures, including the LN .
  • 58.
    1)When removing boneto provide access to and exposure of M3, care Is taken to avoid penetrating the lingual alveolar bone. 2)If lingual bone must be removed to deliver the tooth, the lingual soft tissues (including LN) are protected with a suitable retractor .
  • 59.
    M3 with enlargedfollicular sac or early dentigerous cyst, which has eroded lingual alveolar bone. During removal of soft tissue surrounding M3 crown, surgeon inadvertently removed a portion of the adjacent LN . 4)Removing Soft Tissue Pathology
  • 60.
    (A)When the M3must be sectioned using a high-speed drill, carry the bur only three-fourth of the way through the tooth structure before separating the crown or the roots with an elevator. (B) The IAC (arrows) often lurks just beneath a deeply imbedded horizontally affected M3. 5)Sectioning Teeth
  • 61.
    6)Partial Odontectomy • Ifthe roots lie in intimate contact with the IAC, a partial odontectomy (coronectomy) should be considered. • The roots left in situ may remain in place and rarely, if ever, cause infection or other untoward incident . • In some cases, the roots migrate in a superior direction away from the IAC, allowing their subsequent removal to be nonproblematic.
  • 62.
    (A)Preoperative view ofdistoangular M3 lying adjacent to IAC. (B)Immediate postoperative film showing removal of M3 crown; roots left in situ to avoid injury to IAN. (C) After 5 years, regeneration of bone and no reaction around retained M3 roots are noticed.
  • 63.
    When closing theincision after M3 removal, look for LN before placing needle through lingual soft tissue flap. 7)Placing Sutures
  • 64.
    Neurosensory testing • tograde the level of impairment of sensory function as • normal, or mild, moderate, or severe hypoesthesia, or complete (ie, anesthesia).
  • 65.
    Nerve in Danger! Pain,Pain, Pain • Burning • Severe Autonomic dysfunction • Absence of sweating • Smoothness & dryness of skin Neurotrophic changes • edema • erythema • hypohydrosis • Hypokeratosis
  • 66.
    Algorithm for neurosensorytesting Patient c/o decreased altered sensation Level A (2-point discrimination, direction) Abnormal or absent responses Normal Level B (Contact detection) Increased threshold or no response Normal threshold (Mild hypoesthesia) Level C (Pain sensitivity) Normal threshold (Moderate hypoesthesia) Increased threshold (Severe hypoesthesia)
  • 67.
    Directional discrimination (movingbrush stroke direction identification): the thin black arrows indicate horizontal,vertical, or diagonal directions of the strokes that are applied randomly by the examiner. After each application, the patientis asked to duplicate the direction of the stroke with a cotton swab.
  • 68.
    Level A testingfor 2-point discrimination. (A) (Left) Measurement is begun by contact with the calipers closedtogether. (B) (Right) With each succeeding contact, the caliper beaks are separated by 1 additional millimeter until the patientindicates that 2 simultaneously applied contact points are felt (at 5 mm in this patient).
  • 69.
    Level A testingfor stimulus localization. (A) Five standard contact points (red dots) for stimulus localization. (B) The examiner contacts the patients skin lightly (no skin indentation) with a cotton swab at each contact point. After each contact by the examiner, the patient is asked to contact exactly the same point.
  • 70.
    Semmes-Weinstein monofilament isan alternative method of evaluating static light touch (level B testing
  • 71.
    Vitalometer readings ofthe lower teeth can be used as another method of level C testing for response to painful stimuli
  • 72.
  • 73.
  • 74.
    External decompression -Removalof surrounding bony, soft tissue structures and/or foreign material around the nerve
  • 75.
    Internal neurolysis -Openingof the epineurium to inspect and decompress the nerve fascicles
  • 76.
    Excision of neuroma- Removal of a neuroma associated with a nerve
  • 77.
    Neurorrhaphy - Microsurgicalanastamosis of a transected nerve
  • 78.
    Prerequisites for NerveRepair • Healthy tissue bed • Healthy nerve ends • No undue tension • Adequate soft tissue coverage • Minimal number of sutuers(Three to four sutures) .
  • 79.
    Which of thefollowing is false regarding fibrin glue? a) Fibrin glue is nontoxic and does not block axon regeneration b) It may be used in combination with suture repair c) The outcome of fibrin glue repair is inferior to that of suture repair d) The common components of fibrin sealants include fibrinogen, thrombin and calcium chloride e) It has low tensile strength Tse & Ko. Nerve glue for peripheral nerve reconstruction. IOMFS journal 2012
  • 80.
    Nerve Grafts/Conduits Autologous Source •Nerve autograft • Vein (+/- muscle) Off-the-shelf • Permanent nerve guidance conduit ( silicone) • Polyglycolic acid (PGA) • Caprolactone • Type I collagen Lin et al. Nerve Allografts & Conduits in Peripheral Nerve Repair. IOMFS JOURNAL2013
  • 81.
    Nerve graft -Placement of a nerve graft (allogenic or autogenous) for nerve reconstruction
  • 82.
    Principles of Nervegraft Transfers • Donor nerve near target motor end plates • Expendable donor nerve • Donor-recipient size match • Donor function synergy with recipient function • Sensory re-education improves function Mackinnon SE, Novak CB. BDJ 1999
  • 83.
    (A) LN witha large neuroma (between the arrows) caused by of an impacted third molar removal. (B) The nerve has been repaired with a sural nerve graft (between the arrows) without any tension on the nerve segments
  • 84.
    Intraoral exposure ofthe IAN with a neuroma in continuity secondary to M3 REMOVAL (B) Microsurgical repair using an autogenous nerve graft.
  • 85.
    (A)Sural nerve graftharvest. (B) GAN harvest. (B)(C) Resulting area of anesthesia from a sural nerve harvest.
  • 86.
    Greater auricular nerveharvested using a horizontal incision .
  • 87.
    Guided nerve regeneration-Placement of a conduit to guide axonal sprouting and regeneration across a nerve gap from proximal to distal portions of a nerve
  • 89.
    Gore-Tex conduit usedfor nerve reconstruction, demonstrating the distal repair
  • 90.
    Neuro tube usedas a nerve guide channel
  • 92.
    (A) NeuraGen nerveguide can be used for nerve repair. (B) The NeuroGen tube has been used to repair the IAN.
  • 98.
    (from Kim Y,Haftel VK, Kumar S, et al. The role of aligned polymer fiber-based constructs in the bridging of long peripheral nerve gaps. Biomaterials 2008;29:3117; )
  • 99.
    Neurectomy- Microsurgical transectionand removal of a segment of a peripheral nerve Nerve capping -Covering of the proximal stump of a transected nerve with its epineurium to prevent neuroma formation
  • 100.
    Nerve redirection- Redirectionof a nerve’s sensory innervation to a different anatomic location (usually adjacent muscle); usually done to prevent or minimize deafferentation
  • 101.
    Prognostic Factors ofOutcomes •AgePatient factor • Level of injury (distal vs proximal) • Type of nerve (pure vs mixed functions) • Condition of nerve ends Injury factors • Delay to repair • Length of gap Surgical factors
  • 102.
    Postoperative rehabilitation forthe patient any or all of the modalities listed • Physical therapy • Management of pain syndromes • Counseling, pyschiatric therapy, support group • Restoration of activities of daily living (work, spouse, recreation) • Sensory reeducation • Maintenance of supportive doctor-patient relationship
  • 103.
    Summary • Proper pre-operativeevaluation. • Proper planning of the operative procedure. Can be managed: • Institution of micro –surgical techniques at the right time . Can be avoided: