Current Pain and Headache Reports

https://doi.org/10.1007/s11916-022-01018-w

UNCOMMON AND/OR UNUSUAL HEADACHES AND SYNDROMES (J AILANI, SECTION

EDITOR)

Trigeminal Traumatic Neuroma: a Comprehensive Review

of the Literature Based On a Rare Case
Davis C. Thomas1   · Saranya Devatha Mallareddy2 · Jeffrey P. Okeson3 · Josna Thankachan4 ·
Priyanka Kodaganallur Pitchumani5 · Reshmy Chellam Pichammal2

Accepted: 24 January 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Purpose of Review  Traumatic neuromas in general, and trigeminal traumatic neuromas in particular, are relatively rare
entities originating from a damage to a corresponding nerve or its branches. This manuscript is a comprehensive review of
the literature on trigeminal traumatic neuromas based on an interesting and challenging case of bilateral intraoral lesions.
Recent Findings  The diagnosis for this patient was bilateral trigeminal traumatic neuromas. It is possible that these patients
have a genetic predisposition to the development of these lesions. It is a neuropathic pain condition and may mimic dental
and other trigeminal pain entities. Topical treatment with lidocaine gel, utilizing a custom-made neurosensory stent, rendered
the patient significant and sustained pain relief.
Summary  Trigeminal traumatic neuromas present a diagnostic challenge even to a seasoned clinician, due to the complex
clinical features that may mimic other entities. Topical medications such as local anesthetics may be a good viable alternative
to systemic medications to manage the pain associated with the condition. Early identification of the lesion and the associ-
ated pain helps in the succinct management of symptomatic trigeminal traumatic neuromas.

Keywords  Traumatic neuroma · Oral · Neuropathic pain · Tinel’s sign · Neurosensory stent · Topical medication ·
Trigeminal nerve

Introduction cells, and fibroblasts, in a dense matrix of connective tissue

[1, 2•]. A consensus on the definition of the lesion is lack-
Traumatic neuroma (TrN) is a non-neoplastic condition ing. Pain associated with trigeminal TrN is highly varied,
secondary to trauma (surgical or incidental), characterized including absence of it [3•] and may be provoked or spon-
by the presence of proliferating nerve fibers, inflammatory taneous. The gross appearance of the lesion is described as
a smooth, palpable mass that could be tender or non-tender
This article is part of the Topical Collection on Uncommon and/or on palpation [3•, 4, 5].
Unusual Headaches and Syndromes This comprehensive review is based on a case of bilat-
eral trigeminal TrN occurring in a middle-aged female
* Davis C. Thomas patient. The interesting feature of this case was that the
davisct1@gmail.com
lesions appeared bilaterally, but on different divisions of the
1
Center for TMD and Orofacial Pain, Rutgers School trigeminal nerve, and temporally not related to each other.
of Dental Medicine, Newark, NJ, USA We attempt to discuss the epidemiology, clinical features,
2
Ragas Dental College and Hospital, Chennai, India pathophysiology, investigations, differential diagnosis, and
3
College of Dentistry, University of Kentucky, Lexington, KY,
management modalities of trigeminal TrN based on an
USA exhaustive literature review that we performed.
4
Department of Diagnostic Sciences, Rutgers School
of Dental Medicine, New Jersey, NJ, USA
5
The Ohio State University College of Dentistry, Columbus,
OH, USA

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Case Report
History of Presenting Illness
A 56-year-old Indian female patient presented with chief
complaints of chronic pain in the distribution of the second
division (maxillary, V2) of the left trigeminal nerve and
the third division (mandibular, V3) of the right trigemi-
nal nerve. Her medical history was positive for diabetes
mellitus and hypercholesterolemia, both managed well
with medications. The pain has been existing for the past
approximately 30 years. These two pains had started sub-
sequent to different surgical procedures, separated by a few
years. The quality of the pain had changed over the past 15
to 30 years; the intensity was variable, and she was una-
ble to achieve any meaningful pain relief, although going
through multiple dental procedures in an attempt to do so.
The details of the characteristics of the pain appear below.
Onset
The pain was described as of slow onset.
Location
The reported sites of pain were maxillary left buccal gin-
giva in relation to upper molar tooth (left V2), and man-
dibular right buccal gingiva in relation to the molar tooth
(right V3).
Frequency
The patient reported continuous “background” pain on the
left V2 division, and occasional exacerbations of approxi-
mately twice a week on the same area, and continuous pain
on the right V3 division with nocturnal exacerbations.
Duration
The maxillary left dull background pain was continuous
(hours); the exacerbated pain at the same site of four to 5-h
duration; and the mandibular right quadrant pain as continu-
ous (hours) with nocturnal exacerbations.
Intensity
The intensity of the background pain on the maxillary site
was five to six on a visual analog scale (VAS) of zero to ten.
Exacerbated pain was described as ten on the same scale.
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Current Pain and Headache Reports
With regards to the mandibular pain, she described bursts
of pain intensity of seven on the same scale.
Quality
The background pain had a quality of “dull aching” in both
the arches, and the exacerbated pain had “pulsating” on the
maxillary site, and “shooting” on the mandibular site.
Temporal Characteristics
Over a time period of approximately 30  years, the pain
evolved to a slow chronic progressive type.
Aggravating Factors/Triggers
The pain worsened upon chewing, “after a meal,” acid foods
(such as citrus fruits, cheese, tamarind), and left lateral
recumbent sleep position.
Relieving Factors
None reported.
Response to Past Treatment
Since the onset of the pain, the patient underwent several
dental procedures without any pain relief. The patient also
reported change in the pain characteristics, sometimes for
the worse, every time another dental procedure was done.
Medications that were “tried” included but were not limited
to (varying dosages of) non-steroidal anti-inflammatories
(NSAIDs), anti-epileptic medications, nortriptyline, benzo-
diazepines, and vitamin supplementations. These medica-
tions were relatively ineffective.
Associated Features
None reported.
Radiation/Referral
The exacerbated pain radiated to the temple, eyebrow, preau-
ricular, and postauricular areas.
Association with Sleep
The patient reports a reduced quality of sleep in general. She
is tired during the day and takes sleep aid medications. The
pain does not wake her up from sleep. She does wake up at
her routine waking time and realizes she has pain.
Current Pain and Headache Reports
Clinical Examination Findings
Painful trigger zones in relation to the gingiva supplied by
the maxillary and mandibular divisions of the trigeminal
nerve were identified. These areas were approximately 3 mm
in diameter and looked relatively paler color compared to
the healthy gingiva surrounding them. There were no signs
of inflammation or any pathology in or around these well-
circumscribed trigger zone areas. The patient’s familiar
pain was reproduced by eliciting Tinel’s sign (pain upon
percussion of the lesion). Provocation by light touch did
not reproduce the pain from the trigger zone areas. Local
infiltration of a small amount (0.5 cc) of 3% mepivacaine
without epinephrine, in a close proximity around the trigger
zone (approximately 3–5-mm radius), rendered the patient
complete pain relief.
Management
The TrN was managed effectively with a 5% topical lidocaine
gel, which was retained on the site of the paler color area in
a thermoformed neurosensory stent. The technique of filling
in a minimal amount of the anesthetic in the neurosensory
stent was shown to the patient, and she was prompted to
repeat the same during the same visit. The at-home instruc-
tions were to repeat the same twice daily over a period of
2 months, meanwhile having weekly evaluations at the clinic.
Local anesthetic injection (0.5 cc of 3% mepivacaine without
epinephrine) was administered at every re-evaluation visit.
The symptoms improved gradually over 2 months, and the
patient was completely pain-free at the end of the third month
re-evaluation visit. Concurrently, all the chief complaints
associated with the pain completely dissipated. At the six-
month re-evaluation, the pain associated with the two sites
had almost completely disappeared, with a possible exception
of “occasional twinges” of pain localized to original trigger
zone, upon applying pressure.
Prognosis
With the consecutive anesthetic injections, and employ-
ment of the neurosensory stent with topical anesthetic, the
patient reported approximately 90 percent pain relief from
her chronic familiar pain. Utilizing the non-invasive modali-
ties such as neurosensory stent with topical anesthetic, the
prognosis of this pain condition was good. At the 1-month
and 3-month re-evaluation visits, the patient had almost
complete pain relief on the affected areas. It is indefinite
and probably unknown as to how many months she may
have to continue the neurosensory stent (lack of consensus
guidelines).
Discussion
Definition
Traumatic neuroma is defined as a non-neoplastic repara-
tive/reactive [6–8] lesion of an injured nerve, made up of
rapidly proliferating axons, inflammatory cells, Schwann
cells in a dense fibrous connective tissue stroma [2•, 9,
10].
Classification
Although no universally accepted official classification
exists, most of the literature is in agreement of two types of
TrNs, neuroma in continuity (NIC), and nerve end neuroma
(NEN). The obvious morphological difference between the
two is that there is a continuity of the nerve maintained in
NIC, whereas NEN has the distal portion separated and most
likely disintegrated [11].
Etiology/Pathophysiology
TrN is a lesion that results from an attempted repair by
the nerve [12]. Hypotheses on the proposed stages of TrN
development have been published in the literature [13].
However, to date, there is no absolute confirmation on the
exact sequence or the precise mechanism of development
of TrN. It has been proposed that a combination of nerve
repair, contraction of wound, and scarring (which are a part
of the healing process of the wound), and the accompanying
neuronal proliferation contribute to the formation of TrN
[12, 13]. TrN develops subsequent to an incidental or surgi-
cal trauma [14]. It has also been proposed that lesions that
are not “planned” surgically are incidental, traumatic, or
“unclean” have a propensity to develop TrN [2•, 8]. The type
of force such as compressive and traction has been hypoth-
esized to be of etiological importance in TrN formation [15].
Pro-inflammatory cytokines TNF- α, IL-6, and IL-1β
were shown to be present in significant concentrations in
traumatic neuroma lesions of the sciatic nerve in rats [2•].
It is not clear from the literature whether these inflamma-
tory cytokines play a role in the formation or sustenance
of the lesion, or are a result of the ongoing pathology
within the lesion. Histologically, TrN lesions consist of
a disorganized cluster of proliferating axons, inflamma-
tory and formative cells, embedded in a dense connective
tissue matrix [16, 17]. Earlier studies had indicated that
the most common procedure implicated in the etiology of
trigeminal TrN formation was extraction of teeth [14, 18,
19]. There are isolated reports of oral TrNs secondary to
overextended dental prosthesis [20]. In the head and neck
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region, almost all surgical procedures have been shown to
induce TrN formation [21–24].
Removal of the dental pulp tissue and incision and
drainage of the dental abscess has also been identified
as causative for trigeminal TrN [19]. Some of the newer
literature contradicts this and states that dental surger-
ies (causing intrabony lesions), rather than extractions,
form the main etiological factor for TrN formation [18].
Orthognathic surgeries including chin augmentation [25]
and sagittal split osteotomy have been shown to cause TrN
[26–29] of the affected nerves. The damage to the nerve
could be caused by the use of scalpels, chisels, burs, or by
the compressive forces [25, 27]. There are rare reports in
the literature of TrN being caused by miscellaneous etiol-
ogy such as a burn [6]. Surgical decompression procedures
involving the orbit have been shown to cause TrN of the
divisions of the maxillary nerve (V2), causing continu-
ous excruciating pain [30, 31]. There is also evidence of
infraorbital TrN due to various causes other than surgery,
like bomb blast injury [32]. There are case reports of TrN
occurrence secondary to facial trauma [12]. Rarely, cases
have been reported of unusual occurrences of trigeminal
TrN with such procedures as a halo fixation device [33].
The possible etiology and neuroanatomy of trigeminal TrN
are summarized in Fig. 1.
Fig. 1  Trigeminal traumatic neuroma: etiology, appearance, and gross neuroanatomy of traumatic neuroma pain
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Current Pain and Headache Reports
Epidemiology
Incidence and Prevalence
Prevalence of TrN has been reported with a wide range.
Some studies put the prevalence of oral (trigeminal) TrN at
approximately 0.3% [6, 34]. TrN of the facial nerve is a rare
occurrence with a reported approximate prevalence of 0.002
to 0.8% [35]. In the head and neck region, the reported inci-
dence of TrN is high following parotidectomy (trigeminal
and glossopharyngeal nerve distribution), and neck dissec-
tions [34, 36].
Site Predilection
Painful TrNs constitute one-fourth of all oral TrN cases
[20, 28, 37]. The available literature on head and neck TrNs
alludes to the site predilection, with regards to the affected
nerve, as inferior alveolar, lingual, and greater auricular
nerves, in the descending order of occurrence [6]. Site pre-
dilection has been variably reported by different authors as
mental foramen [28] and intraosseous lesions [18]. Alter-
natively, a slightly different site preponderance referring to
the tissue appears in the literature, as the submental area,
tongue, and labial mucosa [4, 38–40].
Current Pain and Headache Reports
Genetics
Recent studies done using nerve injury models have related
certain proteins and their associated genes as either causing
TrN formation or being responsible for the pain associated
with TrN [41–43].
Clinical Features
In cases of trigeminal TrNs that could be palpated, and/or
observed, the clinical description appearing in the litera-
ture is that of a well-circumscribed lesion, that is neither
ulcerated, nor encapsulated, with a smooth surface [34,
38]. TrN can clinically manifest with a variety of features,
often confusing the clinician. These include, but are not
limited to, significant variations in the frequency, dura-
tion, intensity, quality, radiation/referral, and associated
features. Tinel’s sign, defined as pain along the nerve
distribution upon percussion of the lesion, is described
as one of the cardinal features of typical TrN [44, 45].
However, when the lesion is clinically difficult to palpate
and localize, such as in many intraoral sites, Tinel’s sign
may be a difficult clinical feature to elicit. TrN lesions
may or may not elicit pain [3•]. The incidence of pain in
oral TrN is reported to be approximately 20–30% of the
cases [34, 38]. With regards to pain of intraoral TrNs, the
Fig. 2  Trigeminal traumatic neuroma: pain pathways
lesions occurring on the mental nerve are reportedly most
painful, [3•] whereas some authors describe the lower lip
and tongue as the most common painful sites [14, 28, 34].
The specific set of symptoms depends mainly on such
variables as the nerve affected, and the location of the
lesion along the course of the nerve [13, 28]. The symp-
toms may include both sensory and motor, especially when
specific sites such as the infraorbital nerve are involved
with TrN [32]. Pain from TrN can cross the midline [3•].
Pain associated with TrN has been described as lancinat-
ing, electric, burning, dull aching, or stabbing quality, [3•,
19, 20, 46] similar to neuralgias occurring in the distribu-
tion of the trigeminal nerve [31]. There have been rare
reports of tingling sensation in the area as well [23]. Some
articles refer to sudden cessation of TrN pain, similar to
spontaneous remission seen in cases of trigeminal neu-
ralgia [34]. However, what is unclear in these articles is
whether the diagnosis was trigeminal neuralgia, to begin
with. The neuroanatomic pathways of pain of trigeminal
origin are summarized in Fig. 2. Common aggravating fac-
tors are applying local pressure, [6, 14, 25] percussion, and
palpation of the lesion [18, 47]. Trigeminal TrN can also
be associated with symptoms including neurological (such
as anesthesia, paresthesia, and hyperpathia), autonomic
(such as redness and swelling), and others (such as dizzi-
ness and nausea) [7, 14, 19, 20, 48]
13

Histopathology
TrN contain multiple cut axon ends, Schwann cells, inflam-
matory cells, and dense connective tissue/collagen matrix
[2•, 35]. There are also special markers including S-100
protein, that specifically stains Schwann cells, indicating
presence of multiple myelinated axons [14, 34]. Also present
are Schwann cells and proliferating axons within dense scar
tissue [23, 49]. TrN lacks encapsulation [38, 50].
Investigations
Although the confirmatory test is histopathology, the size
and location of the lesion, many a time, preclude a biopsy
procedure. There is always the inherent risk of resection
of a TrN, ending up in the formation of a new TrN lesion,
which may be even deeper in the tissue to locate. Conse-
quently, reproduction of the patient’s familiar pain, elicit-
ing the Tinel’s sign, and subsequent successful diagnostic
anesthetic blocking of the lesion [46, 51, 52] may be the best
investigative method. The use of imaging such as ultrasound
[22] and MRI [53–55] is also a valuable diagnostic aid for
larger lesions in anatomic areas other than the trigeminal
distribution.
Differential Diagnosis
Based on the clinical features, pain characteristics, and other
features of trigeminal TrN, the most plausible differential
diagnoses include trigeminal neuralgia, painful post-traumatic
trigeminal neuropathy, tumor lesions that can mimic TrN, and
other neuropathic pain entities. The diagnosis is largely by
exclusion, and specific clinical features of TrN, such as Tinel’s
sign. The paradigm followed for diagnosis of trigeminal TrN
is given below.
Diagnosis
Suggested clinical criteria for TrN include post-surgical pain
at the site; neurogenic type of pain; increased pain from trig-
ger zones at the site; and pain relief upon local anesthetic
injection [19, 46]. Local anesthetic block of the lesion has
been proposed as a rapid and cost-effective tool to aid in the
diagnosis and confirmation of TrN [52]. Since there is a lack
of consensus on the exact diagnostic criteria, classification,
and management of TrN, diagnosis becomes one of exclu-
sion of similar entities that may simulate TrN in terms of
clinical features. In this regard, Tinel’s sign is an important
parameter. It must be noted that description of Tinel’s sign
involves “percussion” of the lesion, which may be difficult
or even impossible in trigeminal nerve territories, especially
in the hard to access intraoral sites. Therefore, a modified
version of Tinel’s sign employing palpation/pressure with
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Current Pain and Headache Reports
a cotton bud or digital pressure may be of diagnostic value
[19, 27].
Prevention
Since the inferior alveolar nerve (mandibular nerve) has a
relatively higher incidence of TrN occurrence, alterations
and modifications of surgical techniques have been recom-
mended to minimize trauma to these nerves [29, 56–59].
It has been suggested that, when surgical removal of man-
dibular impacted wisdom teeth is planned, removal of the
crown part of the tooth (a procedure called coronectomy)
reduces the risk of nerve trauma [56, 60, 61]. The accurate
determination of the anatomical position of the tooth/dental
implant with respect to the underlying nerve, prior to sur-
gery, utilizing imaging modalities such as cone beam com-
puted tomography (CBCT) and magnetic resonance imaging
(MRI) or other prudent digital imaging, can help prevent
nerve injuries [62–65]. The adjunctive techniques such as
diathermy and electrical coagulation have been reported
to prevent traumatic neuroma formation, while managing
peripheral nerve injuries [6, 66]. However, it must be noted
that the literature confirming the efficacy of these procedures
in TrN prevention is scanty. In addition, diathermy has also
been used successfully to guide and facilitate the desired
regeneration of the injured nerve [67].
Management
The overall management of trigeminal TrNs may be divided
into conservative, pharmacologic, and surgical approaches.
As alluded to earlier, trigeminal TrN may become a difficult
entity to manage, especially when the lesion cannot be local-
ized sufficiently. Further, although surgical management has
been proposed as the most reliable method for managing
TrN afflicting the larger peripheral nerves (such as the sciatic
nerve), this method could prove extremely difficult and often
impossible when the smaller branches of trigeminal nerve
are involved with the lesion. In addition, there is an inher-
ent risk of a re-occurrence of the lesion at the newly cut end
post-surgical excision. The currently accepted modalities
of management of trigeminal TrN and of the closest most
common differential diagnoses are summarized in Table 1.
Surgical Management
The current modalities available for the management of
trigeminal TrN are limited and include local steroid injection
[3•, 29], local anesthetic (infiltration and topical) [114], and
a combination of these and systemic medications, and surgi-
cal resections [3•, 29, 127, 128]. The use of custom fabri-
cated neurosensory stent has been proposed [114, 119, 120].
There is evidence of successful management of identifiable
 Table 1  Trigeminal traumatic neuroma: differential diagnoses and management
Management modalities Neuropathic pain in general Trigeminal neuropathic pain Traumatic neuroma in general Trigeminal traumatic neuroma

Evidence on prevention
- Modification of surgical techniques - Avoidance of trigeminal nerve
[68] injuries by:
    1. Not using high concentrations
of local anesthetics especially the
ones that can be neurotoxic [69]
    2. Not employing multiple nerve
blocks at the same site [70••]
    3. Appropriate imaging to prevent
- Monopolar diathermy and electrical
coagulation [6, 66, 71]
- Capping of the cut nerve end [72,
73]
- Implantation of cut nerve into the
adjacent muscle [72]
- Local administration of chemicals
such as alcohol, phenol, steroids at
- Administration of systemic steroids
[29]
- Adequately stabilized wiring
without rigidity [29, 59]
- Absolute mobilization of proximal
fragments [29, 57, 59]
- Use of external cortical plate wire
osteosynthesis [29, 58]
Current Pain and Headache Reports

Surgical management
Pharmacological management:
Systemic medications
Topical:
- Neuromodulation via motor cortex
stimulation (MCS) and deep brain
stimulation (DBS) [75]
- Tricyclic antidepressants (TCA) /
Serotonin-
Norepinephrine Reuptake Inhibitors
(SNRI) [90–92]
- Anticonvulsants (gabapentin and
pregabalin) [90, 91, 93, 94]
- Botulinum toxin type A [93, 95]
- Opioids [91, 93]
- Anti-arrhythmics [96]
- Oromucosal cannabinoids [93]
- Capsaicin [93]
- Topical lidocaine [90, 91, 93]
- Topical anesthetics and
combination cream [115]
nerve injury [69]
- Microvascular decompression,
Percutaneous rhizotomy, Gamma
knife radiosurgery, Neuromodulation
via motor cortex stimulation (MCS)
and deep brain stimulation (DBS)
[75]
- Radiofrequency thermocoagulation,
Subcutaneous peripheral nerve
field stimulation [76]
- Steroids [97]
- TCA/SNRI antidepressants [10,
97]
- Anticonvulsants (gabapentin and
pregabalin) [10, 75]
- Botulinum toxin type A [75,
98–106]
- Local anesthetics or 8% capsaicin
patch [97]
- Topical lidocaine [70••, 116]
the site of surgical trauma - Use of thin spatula osteotome [29,
- Use of lasers [72] 58]
- Triamcinolone and 5-fluorouracil
[74]
- Surgical excision [77–79] - Surgical resection [3•, 12, 14, 25,
- Microsurgery, use of nerve grafts 29]
[80, 81]
- Neuromodulatory or reconstructive
modalities [82]
- Regenerative peripheral nerve
interface (RPNI) [83–86]
- Targeted muscle reinnervation
(TMR) [83, 87, 88]
- Cap assisted resection [89]
- Antidepressants [107] Antiepileptic drugs (carbamazepine
- Anticonvulsants [108] and gabapentin) and pregabalin
- Calcitonin [82, 108] [114]
- Calcium channel blockers [82]
- Beta-blockers [82]
- Perineural/neuraxial analgesia with
local anesthetic and morphine
[109–111]
- TNF-a blockers (etanercept) [112,
113]
- Local injections of steroids [117, - Use of neurosensory stent [114, 119,
118••] 120]
- Local steroid infiltration [3•]

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 Current Pain and Headache Reports

trigeminal TrNs using surgical excision of the lesion [25,

29]. Surgical excision of the lesion may predispose to the
development of a new TrN at the fresh-cut end. Systemic
Trigeminal traumatic neuroma

percussion, ultrasound [14] medications may help manage residual pain after surgical
- Stereotactic radiosurgery,

excision [28].

Pharmacological Management

Systemic medications that belong to several classes of drugs

have been used to manage the pain of trigeminal TrN with
limited efficacies. These medications include antiepileptic
- Ultrasound-guided steroid injections

drugs (carbamazepine and gabapentin) and pregabalin [31,

114, 117, 129]. The use of custom fabricated neurosensory
neurolysis and radiofrequency
Traumatic neuroma in general

stent has been proposed [114, 119, 120].

- Ultrasound-guided alcohol
- Psychological, cognitive-behavioral - Electrostimulation [112]

Complications and Prognosis
ablation [126]

Chronic pain, often intractable, can be a complication sig-

nificantly affecting the quality of life of patients with TrN.
[125]

Many of these patients, as is in our current case, go through

multiple procedures (including surgical) resulting in either
more chronic pain and/or complications from the proce-
dures themselves [14, 130]. Irreversible dental treatments
approaches and hypnosis [97]

performed by clinicians lacking knowledge about trigeminal

Trigeminal neuropathic pain

neuropathic pain, in general, are not indicated and may often

lead to unfortunate results in many cases. Further, although
surgical excision may be one of the more prominent man-
agement modalities proposed in the literature, it should be
borne in mind that there is a significant inherent risk of a
recurrence, especially when there is a possible genetic predi-
lection, as is apparent in our current case [3•, 14, 131]. With
early diagnosis, and management by a competent clinician,
relaxation, pressure, yoga, exercise

well versed in management of neuropathic pain, trigeminal

hypnosis, biofeedback, massage,

TrN can be thought of as having a fair to good prognosis.

- Physical therapy, acupuncture,
- Cognitive-behavioral therapy,

- Spinal cord stimulation [123]

Neuropathic pain in general

- Transcutaneous magnetic
mirror therapy [91, 121]

- Electrotherapy [96, 122]

- Counseling [70••, 96]

Case Discussion in the Context

stimulation [124]

of the Literature

Clinical Presentation
[96]

Bilateral TrN lesions of the trigeminal nerve, the diagnosis

in the current patient, are rarely reported in the literature.
Ultrasound-guided phonophoresis,

The lesion is classically described as unilateral (second-

Alternative therapies (physical
therapy, massage Cognitive

ary to trauma) [132]. The time elapsed from initial onset of

symptoms to diagnosis in our current case is approximately
Management modalities

30 years, which is unusual and inconsistent with the known

behavioral therapy,
Table 1  (continued)

literature of similar lesions in other anatomic locations [107,

iontophoresis)

133–135]. The fact that the patient had developed the lesion
after surgical procedures is consistent with the available lit-
erature [18, 25–28] The pain characteristics of the current
case, as they relate to the literature, are given below.

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Current Pain and Headache Reports
Onset
Many authors report the onset of symptoms to be ranging
from soon after the trauma of a surgical event has occurred,
to several weeks after the same [5]. In our present case,
there was no such definite temporal pattern reported by the
patient. TrN of other anatomic sites have been reported to
become symptomatic months following the surgical event
[136].
Location
Consistent with the literature, this case exemplifies TrN of
the terminal branch of V2 and V3 divisions of the trigem-
inal nerve [6]. However, the occurrence of two anatomi-
cally independent lesions in the same patient (left and right
sides and differing branches of the trigeminal nerve) is a
unique feature of this case that is largely inconsistent with
the established TrN literature. Considering the variability
of clinicians and procedures between the two sites/sides,
we the authors strongly feel that there might be a genetic
predisposition in this patient to TrN formation. Genetic pre-
disposition to neuropathic pain has been published in the
literature [137].
Frequency
We could not find pertinent focused literature on the nature
of the background pain or frequency of pain associated with
trigeminal TrN.
Duration
The continuous nature (“hours”) of the background pain in
this particular case is in agreement with past literature on
similar TrNs in other anatomic areas of the body [28, 107].
Intensity
Intensity of the pain varying from five to six (moderate)
on a numerical pain scale of zero to ten is at par with the
literature for oral and extraoral sites of TrN [19]. The seven
out of ten pain (severe) for the exacerbated episodes is also
consistent with much of the published literature for TrN in
trigeminal and other nerve distributions [28, 29, 107].
Quality
The description of dull aching background pain goes along
with the published literature in the oral and extraoral sites of
TrN [29]. However, the pulsating quality of exacerbated pain
is inconsistent with the published literature of TrN, which
reports a higher frequency of shooting, tingling, electric, and
burning types of pain [3•, 18, 29, 112].
Temporal Characteristics
Although the slow chronic progressive nature of this
patient’s case is consistent with much of the neuropathic
pain literature, the 30-year chronicity of this pain is unusual
[19, 28].
Aggravating Factors/Triggers
The triggering of the pain in the present case, by functions
such as chewing, talking, and jaw movements, is consistent
with the current literature [18, 19, 28, 29, 112, 138]. How-
ever, the aggravation of pain by acidic foods, citrus fruits,
and sleep position is rather unusual.
Relieving Factors
The lack of relieving factors for the background pain (as
was in this case), and relief achieved by complete rest to the
affected areas (thereby avoiding triggers), and by the use of
topical anesthetics are consistent with the current literature
on trigeminal TrN [120].
Response to Past Treatment
The fact that our current patient had no relief from pain
even after multiple dental procedures is consistent with the
published literature [14, 130]. The lack of response to mul-
tiple drugs, although part of published literature, the specific
absolute lack of pain relief upon trial of anti-seizure and
SNRI medications (gabapentin, carbamazepine, nortriptyl-
ine) seems consistent with the literature [117].
Associated Features
As different from this case, associated features of skin/
mucosal changes, paresthesias, dysesthesias, and auto-
nomic features have been reported in the literature [14, 19,
29, 139–141].
Radiation/Referral
Referral pattern in this patient’s case goes along with the
published literature of pain in the distribution of the affected
nerve [8, 29, 142, 143].
13

Association with Sleep
The lack of association with sleep disturbances, as observed
in this case, is not consistent with the current literature on
neuropathic pain [19].
Investigations
The size of the TrN lesion in this case as elicited clinically is
consistent with the literature on trigeminal TrN [34]. Repro-
duction of patient’s familiar pain from the local TrN lesion
is one of the clinical methods to confirm the location of
the lesion. Specifically, eliciting a Tinel sign is considered
one of the clinical diagnostic features of TrN in the other
anatomic areas of the body [44, 45, 121]. The pain relief
obtained in this case by both topical and infiltration of local
anesthetic goes along with the published literature [46, 52].
Management
Specific guidelines for the management of TrN lesions in
general, and trigeminal TrN lesions in particular, are lacking.
TrN is considered a neuropathic pain entity [2•, 107, 144].
Conceivably, management modalities that work for neuro-
pathic pain in general may work very well for TrN lesions
as well. One of the medications used in management of neu-
ropathic pain conditions similar to TrN is topical lidocaine
[145, 146]. In an attempt to retain the topical medications
such as lidocaine at the site of the lesion, a custom fabricated
dental stent may be utilized [114].
Clinical Pearls
For clinicians who manage pain, there are certain take-home
pearls from the case and the review. We strongly believe that
awareness and education for all clinicians (dental, medical,
allied health, and specialists) are paramount in the early rec-
ognition and succinct management of trigeminal TrN. This
definitely would help improve quality of life for the patient,
help avoid unnecessary procedures, and bring optimal pain
relief to the patient. An interdisciplinary team consisting
of physicians, pain management specialists, dentists, neu-
rologists, and orofacial pain specialists is the best hope for
patients with difficult-to-diagnose entities such as trigemi-
nal TrN. The clinician should also understand that there
are other entities that may mimic signs and symptoms of
trigeminal TrN, and the diagnosis, many a times, is by exclu-
sion. The astute clinician should recognize the entity, and
make a timely, prompt, appropriate referral to the specialist
for management of trigeminal TrN. After the diagnosis of
13
Current Pain and Headache Reports
trigeminal TrN has been established, the clinician should opt
for conservative modalities such as topical pharmacotherapy,
possible systemic pharmacotherapy, and adjunct modalities,
thereby avoiding aggressive surgical treatments and possibil-
ity of recurrence.
Conclusion
Traumatic neuromas in general, and trigeminal TrNs in
particular, present with varied clinical features, and may
pose a diagnostic challenge to the clinician. TrN is a neuro-
pathic pain condition that results from attempted repair by
an injured nerve. When TrN occurs in the trigeminal nerve
distribution, they present as small, non-encapsulated, often
non-palpable lesions making it difficult to palpate. The diag-
nosis of this neuropathic pain entity is often by exclusion of
other similarly behaving entities and eliciting classic features
such as Tinel’s sign. Surgical resection, although may be a
choice, may have limited value due to the relative inability
to locate the lesion and probably running the risk of a recur-
rence of the entity. Systemic medications may help; how-
ever, topical medications form the choice of management,
due to reduced risk of side effects and better efficacy from
localized application. Further, the use of custom fabricated
delivery methods, such as a stent, further increases the effi-
cacy by successfully retaining the medication locally for a
longer time. There may be a genetic predilection for patients
to form TrNs subsequent to incidental or surgical trauma.
There is a necessity for consensus amongst the pioneer pain
management organizations as to diagnostic criteria, manage-
ment protocols, and classification of TrNs.
Author Contribution  Davis C. Thomas: conceptualization, investi-
gation, methodology, writing/reviewing/editing, analysis. Saranya
Devatha Mallareddy: writing/reviewing/editing, literature search.
Jeffrey P. Okeson: writing/reviewing/editing, literature search. Josna
Thankachan: writing/reviewing/editing, literature search. Priyanka
Kodaganallur Pitchumani: writing/reviewing/editing, literature search.
Reshmy Chellam Pichammal: writing/reviewing/editing, literature
search, investigation, methodology, medical illustrations.
Compliance with Ethical Standards 
Conflict of Interest Davis C Thomas, Saranya Devatha Mallareddy,
Priyanka Kodaganallur Pitchumani, Reshmy Chellam Pichammal,
Josna Thankachan, and Jeffrey P Okeson declare no conflict of interest.
Human and Animal Rights and Informed Consent  This article does not
contain any studies with human or animal subjects performed by any
of the authors.
Current Pain and Headache Reports
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