Inferior Alveolar and Inferior Alveolar and Lingual Nerve InjuriesLingual Nerve Injuries

Algorithms for ManagementAlgorithms for Management

Scenarios of Nerve InjuryScenarios of Nerve InjuryInferior Alveolar NerveInferior Alveolar Nerve

OdontectomyOdontectomy Following injectionFollowing injection Following endodonticsFollowing endodontics Following implantsFollowing implants Following genioplasty with or without Following genioplasty with or without

BSSOBSSO

Scenarios of Nerve InjuryScenarios of Nerve InjuryLingual NerveLingual Nerve

OdontectomyOdontectomy Periodontal surgeryPeriodontal surgery Following injectionFollowing injection Screws of BSSO fixationScrews of BSSO fixation

Tests of Nerve InjuryTests of Nerve Injury

MappingMapping Mapping with tactile, thermal and pulp Mapping with tactile, thermal and pulp

stimulationstimulation Serial tactile and thermal testsSerial tactile and thermal tests Clinical test algorithms with tactile and painful Clinical test algorithms with tactile and painful

stimulistimuli Somatosensory evoked potentialsSomatosensory evoked potentials MicroelectroneurographyMicroelectroneurography Electronic thermographyElectronic thermography Taste with vital staining-videomicroscopyTaste with vital staining-videomicroscopy Magnetic source imagingMagnetic source imaging

The Five Radiographic SignsThe Five Radiographic Signs11

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

Radiographic Risk FactorsRadiographic Risk FactorsX-ray X-ray findingfinding

SensSens(%)(%)

SpecSpec(%)(%)

PPVPPV(%)(%)

NPVNPV(%)(%)

PPVPPV(%)(%)

NPVNPV(%)(%)

DiversionDiversion 5050 8282 3434 8989 2.72.7 9999

DarkeningDarkening 6565 7373 3131 9393 2.32.3 9999

InterruptionInterruption 8080 5454 2525 9393 1.71.7 9999

Any findingAny finding 100100 3333 2222 100100 1.41.4 100100

Case for Early RepairCase for Early Repair

Animal studies – most support early Animal studies – most support early repair, but some success laterepair, but some success late

Humans – difficulty comes from Humans – difficulty comes from comparison of direct repairs vs. grafts, comparison of direct repairs vs. grafts, IAN and lingual nerve “lumping”, IAN and lingual nerve “lumping”, inconsistent indications and lack of inconsistent indications and lack of randomized controlled trials for outcomesrandomized controlled trials for outcomes

Questions for treatmentQuestions for treatment

Frame the dilemma as an evidence-based Frame the dilemma as an evidence-based questionquestion

Retrieve applicable, valid and current Retrieve applicable, valid and current evidence to answer the questionevidence to answer the question

Appraise the evidence for applicability and Appraise the evidence for applicability and validity. What are the results?validity. What are the results?

Using Ultrasound to Using Ultrasound to Visualize the Visualize the Lingual NerveLingual Nerve

Presented by James OlsenPresented by James OlsenHSDM 2006HSDM 2006

January 20, 2006January 20, 2006

http://i.cnn.net/cnn/2003/HEALTH/08/27/ultra.stethoscope/story.portable.ultrasound.jpg

Mandibular Nerve BranchesMandibular Nerve Branches

A. AuriculotemporalB. LingualC. Inferior AlveolarD. N. to the MylohyoidE. MentalF. Buccal

http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/h_n/cn/cn1/images/cnb3.jpg

Lingual Nerve AnatomyLingual Nerve Anatomy

The lingual nerve crosses the submandibular duct twice in the paralingual space.

http://www.sciential.net/images/Clemente2f.jpg

Lingual Nerve AnatomyLingual 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.

Lingual Nerve InjuryLingual 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

Treatment of Lingual Nerve Treatment of Lingual Nerve InjuriesInjuries

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

Case ReportCase Report

*Images courtesy of Dr. Donoff

Case ReportCase Report

Imaging of Lingual Nerve InjuriesImaging of Lingual Nerve Injuries

CT

Imaging of Lingual Nerve InjuriesImaging 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

Using Ultrasound to Using Ultrasound to Visualize the Lingual NerveVisualize the Lingual Nerve

http://www.bbc.co.uk/health/images/300/ultrasound.jpg

UltrasonographyUltrasonography

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

UltrasonographyUltrasonography

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

UltrasoundUltrasound

A pulse is generated and transmitted from the A pulse is generated and transmitted from the transducertransducer

– Frequency - number of repetitions per second (Hertz)Frequency - number of repetitions per second (Hertz)– Wavelength - distance between excitations (0.1 – 1.5 mm)Wavelength - distance between excitations (0.1 – 1.5 mm)

High frequency + short wavelength = Better resolutionHigh frequency + short wavelength = Better resolution– Amplitude - measured in decibelsAmplitude - measured in decibels– Period - time necessary for one cycle to occurPeriod - time necessary for one cycle to occur

(piezoelectric crystals)

StudyStudy

Sonosite 180 Plus HST transducer (25mm, 10-5 MHz).

StudyStudy

Yorkshire cadaverpig head

OMFSEndoscopic Research Center

StudyStudy

Surgery, Anesthesia, & Experimental Techniques in Swineby M. Michael Swindle, DVM

StudyStudy

Yorkshire cadaverpig head

StudyStudy

Yorkshire cadaverpig head

StudyStudy

StudyStudy

StudyStudy

Table 1: Summary Diagnostic Outcomes for Three Evaluators

PigPig KeyKeyEvaluator #1Evaluator #1(Radiologist)(Radiologist)

Evaluator #2Evaluator #2(Senior Surgeon)(Senior Surgeon)

Evaluator #3Evaluator #3(Surgical Fellow)(Surgical Fellow)

11RightRight

Partial Partial TransectionTransection

IntactIntact IntactIntact Partial TransectionPartial Transection

LeftLeft Nerve IntactNerve Intact Full TransectionFull Transection IntactIntact Full TransectionFull Transection

22RightRight Partial Partial

TransectionTransectionPartial TransectionPartial Transection IntactIntact Full TransectionFull Transection

LeftLeft Full TransectionFull Transection Full TransectionFull Transection Full TransectionFull Transection IntactIntact

33RightRight Nerve IntactNerve Intact IntactIntact IntactIntact IntactIntact

LeftLeftPartial Partial

TransectionTransection Partial TransectionPartial Transection Partial TransectionPartial Transection Partial TransectionPartial Transection

44RightRight Full TransectionFull Transection Full TransectionFull Transection Partial TransectionPartial Transection Full TransectionFull Transection

LeftLeft Nerve IntactNerve Intact IntactIntact IntactIntact Partial TransectionPartial Transection

55 RightRight Full TransectionFull Transection Partial TransectionPartial Transection Full TransectionFull Transection Full TransectionFull Transection

Number of Correct Number of Correct Diagnoses (%)Diagnoses (%)

6 (66.7%)6 (66.7%) 6 (66.7%)6 (66.7%) 5 (55.6%)5 (55.6%)Average 17 / 27 (63%)

ResultsResults

ResultsResults

Table 2: Average distance of lingual nerve from alveolus as measured with ultrasound

PigPigAve. distance from alveolus (mm)Ave. distance from alveolus (mm)

11RightRight 0.00.0

LeftLeft 1.8671.867

22RightRight 2.7562.756

LeftLeft 0.5330.533

33RightRight 0.00.0

LeftLeft 1.9561.956

44RightRight 0.9780.978

LeftLeft 0.3560.356

55 RightRight 0.7110.711

AverageAverage 1.021.02

ResultsResults

Yorkshire cadaverpig head

Case ReportCase Report

*Images courtesy of Dr. Donoff

DiscussionDiscussion

– It is in fact possible to see the lingual nerve with It is in fact possible to see the lingual nerve with ultrasoundultrasound

– The result is near statistically significance – it is very The result is near statistically significance – it is very likely that a larger sample size is needed to detect likely that a larger sample size is needed to detect

the the difference as power may establish statistical difference as power may establish statistical significance for a relatively small effect size.significance for a relatively small effect size.

– The pig nerve is closer to the alveolus than it is in the The pig nerve is closer to the alveolus than it is in the human human

– Pig nerve is roughly ¼ the size of the human nervePig nerve is roughly ¼ the size of the human nerve

ConclusionConclusion

– The results of this study show that The results of this study show that ultrasonography can be used to visualize the ultrasonography can be used to visualize the lingual nerve. Further studies and higher lingual nerve. Further studies and higher quality imaging are needed in order to quality imaging are needed in order to

determine the extent of involvement that determine the extent of involvement that ultrasound might have in both the prevention ultrasound might have in both the prevention and surgical planning process of lingual and surgical planning process of lingual

nerve nerve injuries.injuries.

Susarla et al. JOMFS 65:1070, 2007

Susarla et al.JOMFS 65:1070, 2007

Susarla, et al. JOMFS 65:60, 2007

Susarla, et al. JOMFS 65:60, 2007

Hillerup and Stoltze. IJOMFS 36:1139, 2007

Hillerup and Stoltze IJOMFS 36: 1139, 2007

Hillerup and Stoltze IJOMFS 36:884, 2007

Hillerup and Stoltze IJOMFS 36:884, 2007

Caveats from ExperienceCaveats from Experience

Lingual nerve injuries usually not painfulLingual nerve injuries usually not painful Trigger in LN injuries with anesthesia positive Trigger in LN injuries with anesthesia positive

findingfinding IAN injuries often painfulIAN injuries often painful Operated IAN injuries often develop pain Operated IAN injuries often develop pain

syndromessyndromes Age is a very important factorAge is a very important factor Rare for anesthetic lingual nerve patients with Rare for anesthetic lingual nerve patients with

Tinel’s like sign to recoverTinel’s like sign to recover