Journal of the Canadian Dental Association
June 2004, Vol. 70, No. 6Blanas, Kienle, Sándor
traditional classification schemes with applicability tomechanical nerve injuries have been described by Seddonand Sunderland.
If the nerve injury in this case wassolely due to mechanical causes, it could be classiﬁed as aneurotomesis (Seddon) or as a third, fourth or ﬁfth degreeinjury (Sunderland). These injuries are characterized by apoor prognosis for recovery, as there is severe disruption of all of the components of the nerve trunk.
As a result of the poor prognosis and because of the possibility that asyptomatic neuroma will develop, surgical intervention isoften considered in such cases.The theoretical beneﬁt of early surgical intervention anddecompression of the nerve is the potential for the restora-tion of the neural microvasculature, possibly enhancingrecovery of the nerve. However, there are deﬁnite risksof surgery, including nerve transection, as well as furthernerve damage, which may lead to complete anesthesia ordysesthesia.The possibility of microreconstructive surgery shouldalso be explored. However, nerve grafting may cause both-ersome paresthesia in the sensory distribution of the donorsite nerve. Although the sural nerve and the greater auricu-lar nerve may be considered as possible donor sites, thelong-term sensory deﬁcit resulting from the transplantationof these nerves may result in permanent numbness in theirdistributions in the lower extremity or the ear lobe.
The current case illustrates the dilemma in decidingwhether surgery is indicated, given that the exact etiology of the injury cannot be determined. Fanibunda and others
have reported on early surgical intervention undertaken ina similar clinical situation with very limited success. Ourpreviously reported case
describes equally poor outcomeswith a nonsurgical course. In the current case, surgicaloptions were initially limited by extraneous factors, such asthe patient’s cardiac status. The gradual improvement in thepatient’s clinical signs and symptoms, as well as the signiﬁ-cant risks of surgery resulted in the decision by both patientand practitioners to maintain a nonsurgical course. Furtherimprovement may occur, although the ultimate outcomecannot be predicted.We propose the algorithm shown in
as a possiblestrategy for managing thermoplastic injuries of the inferioralveolar nerve. Unfortunately, the literature currently provides little guidance with respect to evidence-based deci-sion making and treatment planning in this setting. Speciﬁcsurgical approaches are selected on the basis of which offersthe greatest access to affected nerve segments in the variousareas of the inferior alveolar nerve as it courses through themandible. In the mid-body of the mandible, in the premo-lar and ﬁrst molar area, a lateral corticotomy may be desir-able; whereas in the more posterior zones of the lower jaw,in the molar region, a sagittal split osteotomy may providebetter access (
). Not included in the algorithm arerecommendations for dealing with painful dysesthesia.In these cases, surgical or pharmacologic treatment may ultimately be required.
It seems logical that if the only injury sustained by anerve is compression, then surgery to remove the cause asearly as possible could be beneﬁcial. This may enhance thepotential for reperfusion of the compressed nerve andimprove its ability to recover. With the additional insult of a thermal injury, the extent of injury becomes difficult todetermine clinically and the beneﬁts of early surgical inter-vention are uncertain. More cases are needed to validate ourproposed protocol for managing combined thermal andcompression injuries of the inferior alveolar nerve.
Symptomatic thermoplastic nerve injuryEarly (within 24 hrs) Late (after 24 hrs)Tooth extractionLateral decompression(tooth 4-6)Sagittal split osteotomy(tooth 6-8)Successfulremovalof gutta-perchaGutta-percharemnantsSuccessFailure Success FailureLateral decompression(tooth 4-6)Sagittal split osteotomy(tooth 6-8)ObservationSurgery -NeurorhaphyNerve graftingSpontaneous recovery No improvement
A suggested algorithm for the management of thermoplastic inferior alveolar nerve injuries.