SCARANO ET AL
Neurosensory Disturbance of the Inferior
Alveolar Nerve After 3025
Implant Placements
Antonio Scarano, MD, DDS,* Bruna Sinjari, DDS,† Giovanna Murmura, DDS,‡ and Felice Lorusso, DDS†
he loss or functional insuffi-
T ciency of bone tissue represents
one of the most frequent prob-
lems in implant prosthetic rehabilita-
tion in the posterior mandible. To
avoid these problems, different re-
generative surgical techniques have
been developed: conventional onlay/
inlay grafts, interpositional sandwich
osteotomies, guided bone regenera-
tion with semipermeable membranes,
piezoelectric stimulation, and alveolar
distraction osteogenesis procedures.1–
3 Mandibular bone atrophy makes
it more susceptible to invasion of
the inferior alveolar nerve (IAN) dur-
ing implant site preparation and dur-
ing implant placement.4,5 Iatrogenic
injury to the IAN is an important clin-
ical eventuality that may occur during
implantology, with postoperative dys-
esthesia in a range between 1.7% and
43.5%, and permanent sensory distur-
bance (after more than 1 year) of 5%
to 15%.6,7
*Professor, Department of Medical, Oral and Biotechnological
Sciences, CeSI-Met University “G. D’Annunzio” of Chieti-
Pescara, Chieti, Italy.
†Resident, Department of Medical, Oral and Biotechnological
Sciences, University “G. D’Annunzio” of Chieti-Pescara, Chieti,
Italy.
‡Professor, Department of Medical, Oral and Biotechnological
Sciences, University “G. D’Annunzio” of Chieti-Pescara, Chieti,
Italy.
Reprint requests and correspondence to: Antonio
Scarano, MD, DDS, Department of Medical, Oral and
Biotechnological Sciences, University “G. D’Annunzio,”
Via dei Vestini, 66100 Chieti (CH), Italy, Phone: 0871-
3554084, Fax: 0871-3554099, E-mail: ascarano@unich.
it
ISSN 1056-6163/17/02605-001
Implant Dentistry
Volume 26
Number 5
Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000651
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IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017
Purpose: The aim of this retro-
spective study was to evaluate the
incidence of inferior alveolar nerve
(IAN) lesion and duration of sensi-
tivity disturbances after the insertion
of dental implants.
Methods: One thousand sixty-five
patients (mean age: 58.9 years)
enrolled between February 2004 and
July 2015 with partial or full mandib-
ular edentulism were selected to receive
dental implants for oral rehabilitation.
A total of 3025 implants were placed.
After surgical procedures, controls
were scheduled at suture removal, that
is, 10 days after surgery, and repeated
at intervals of 1, 3, and 6 months, and
comprised patient interview, clinical
examination, and sensitivity tests.
The IAN lesion in implantology
can be related to direct and indirect
different pathogenetic mechanisms that
may overlap:
1. direct compression determined by
the dental implant penetrating into
the mandibular canal;
2. indirect compression deter-
mined by bone trabeculae driven
onto the nerve by an implant
placed close to the mandibular
canal;
3. nerve section induced by trau-
matic penetration of the drills in
the mandibular canal during
implant site preparation;
4. bone overheating during implant
site preparation;
1
Results: Only 23 (2.2%) of the
1065 patients presented sensitivity
disturbances 1 month after implant
insertion, and only 2 (0.19%) after 6
months, though a complete recovery
was observed in these patients within
13 months.
Conclusions: Considering the
debilitating effects resulting from
IAN lesion and the complexity of
the therapeutic diagnostic proto-
cols, all patients undergoing oral
rehabilitation through dental im-
plants should be evaluated with
CBCT imaging. (Implant Dent
2017;26:1–9)
Key Words: dental implants, periph-
eral nerve injuries, iatrogenic
lesion, sensitivity disorders
5. stretching due to mishandling of
the mental nerve (with elongation
greater than 20%) during flap dis-
section or maneuvering of IAN
transposition in edentulous man-
dibular saddles with strong alveo-
lar bone resorption.
Injuries to the IAN during surgical
procedures may also be determined
by the use of troncular anesthesia: in
particular, such injuries are attributable
to trauma produced by the needle of
a second anesthesia and by the bleed-
ing that occurs around the nerve after
the introduction of the anesthetic, and
in some cases, also from the metabo-
lism of lidocaine.8 Lastly, one of the
causes is the extreme variability of
2 NEUROSENSORY DISTURBANCE SCARANO ET AL

the anatomic course of the inferior
alveolar nerve.9
Nerve lesions can be distinguished
according to the prognosis and the time
required for various levels of recovery
according to Seddon, and as amended
by Sunderland:10,11
1. neurapraxia: it is a temporary
stopping of conduction in the
absence of anatomical lesions of
the nerve trunk; restitutium ad in-
tegrum of the function after a lim-
ited period of days or months. This
is the lightest injury which occurs
from physical damage of the mye-
lin sheath and from ischemia by
compression of the vessels supply-
ing the nerve (rapidly reversible).
There is a slight deficit of electrical
nerve conduction, while the ana-
tomical continuity of the nerve is
intact. Spontaneous resolution oc-
curs in a few days to 3 weeks;
2. axonotmesis (Class I): it is an inter-
ruption of the axon only with intact
connective tissue sheaths (endoneu-
ral tube) due to a contusion or crush-
ing. The myelin sheath remains
intact, while the axis-cylinder is in-
terrupted with distal degeneration,
that is necrosis with loss distal to
the lesion; after Wallerian degener-
ation of the distal fiber axons, neu-
ronal gems tend to restore the
continuity of the nerve; the frame-
work improves within 2 to 4 months
with partial or total recovery;
3. neurotmesis (Class II): it is a com-
plete section of the nerve with
breakage and loss of continuity
of the endoneural tube; healing is
proportional to the size of the sec-
tion, and the Wallerian regenera-
tion can be more or less complete,
slow (6–24 months), incomplete,
and often absent with the forma-
tion of neuromas, schwannomas,
or neurilemomas;
4. axonal stenosis (Class III): it con-
sists of a chronically compressed
nerve segment, leading to progres-
sive degeneration (axon cachesia).
It is the more serious lesion as the
entire nerve trunk is separated with
distal degeneration of axons.
From the symptomatic point of
view, a lesion of the IAN can cause:
dysesthesia, characterized by abnormal

Fig. 1. Detection of the mandibular canal by multiplanar CT reconstruction and visualization of interface for correct placing the implant in
mandible. Implant placement in contact with the mandibular canal region.

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SCARANO ET AL IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017 3

sensations not originating from an ade-
quate sensory stimulus; paresthesia,
characterized by tingling, perception of
hot, cold and stings in the absence of
stimuli; hypoesthesia, reduced suscepti-
bility to sensory stimuli; anesthesia, lack
of sensitivity; hyperesthesia, increased
sensitivity to normal stimuli.8,9
From a functional point of view, any
traumatic event on a nerve leads to loss
of excitability, which can arise very
quickly (30–90 minutes), in the event
of ischemic damage, or more gradually
(3–8 days), in case of direct section.12
The healing of nerves, depending on
the different histopathological changes in
the damaged fibers, is divided into 4
different phases, ranging from an initial
phase, related to the healing of the nerve
cell body and clinically corresponding to
a neurapraxic syndrome, up to a gradual
recovery of nerve excitability, in case of
complex lesions which are characterized
by axonal growth (1 mm per day) and the
activity of reworking of the new periph-
eral input by the central nervous system.13
The scientific literature on dental implants
includes among its complications a vary-
ing degree lesion of the IAN, which can
lead to different types of clinical phenom-
ena with different clinical symptoms.14
The aim of this retrospective
study was to evaluate the incidence and
reasons of inferior alveolar nerve lesion
and duration of sensitivity disturbances
after the insertion of dental implants.
MATERIALS AND METHODS
A total of 1065 patients (mean age ¼
58.9 years) with partial or full mandibular
edentulism who had elected to receive
3025 dental implants (of which 125
were short implants) underwent pros-
thetic rehabilitation between February
2004 and July 2015 at the Department
of Medical, Oral and Biotechnological
Sciences of the University “G. D’An-
nunzio” of Chieti-Pescara. Patients
with IAN injury during dental implant
placement were recruited for the study.
All implants were placed distal to the
mental foramen projection. The sub-
jects evaluated in the present study
had to fulfill the following inclusion
criteria:
1. They had had unilateral or bilat-
eral iatrogenic IAN injury with
neurosensory disturbance after
dental implant surgery;

Fig. 2. Patient referred for evaluation of neurosensory disturbances in the region of the mental nerve following implant placement in the first
molar region of the right posterior mandible. The CBCT images show that implant is inserted partially into the mandibular canal region.

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4 NEUROSENSORY DISTURBANCE SCARANO ET AL

of the oral mucosa, and was aimed at

Fig. 3. CT scan showing invasion of the mandibular canal during preparation of the implant
site. Illustrating implant bed after removal of implant within 24 hours, with successful resolution
of IAN injury within 3 days.
2. Patients had no IAN sensory distur-
bances in the surgery sites before
the treatment.
All implant insertions were per-
formed under local anesthesia, after
10 days from surgical intervention,
the patients were recalled for suture
removal and the sensitivity was evalu-
ated. Only patients with IAN sensory
disturbances were recalled at intervals
of 1, 3, and 6 months after the implant
insertion according to the protocol of
Zuniga et al, which also included
patient interviews, clinical examination
and sensitivity tests.15,16
Patient interviews had the main
purpose to establish if there was pain,
unpleasant sensations, or if there was
a reduction of the subjective sensitivity.
A series of questions were done to
which the patient responded as pre-
cisely as possible.
Clinical examination consisted in the
detection of traumatic self-induced inju-
ries to the lips, percussion and palpation
identifying trigger areas, whose stimula-
tion leads to the perception of an electric-
like sensation or vibration, which may be
limited to that area or radiate to the
surrounding skin. Sensory tests included
a series of tests that were carried out to
assess the sensitivity to touch, tempera-
ture, pain sensation and taste.
Tactile sensitivity was evaluated by
tapping the affected area of the mucosa
with a blunt object, and also consider-
ing the minimum distance at which 2
points were perceived as separate
points, as previously described.17
Thermal sensitivity was tested by
placing hot or cold objects in contact
with the mucous membranes and the
skin.
Finally, pain sensitivity was eval-
uated by pinching with surgical twee-
zers the affected area or pricking with
a probe.18
Following the neurosensory assess-
ment, x-ray examination (CT or cone
beam CT) was performed.
The spiral CT scans were all carried
out with a Somatom plus SA CT
scanner (Siemens, Erlangen, Germany)
following a standard exposure protocol
that was developed by the Department
of Medical, Oral and Biotechnological
Sciences University “G. D’Annunzio”
of Chieti-Pescara, Italy.
The positivity of this sign also
allowed a selection of patients requiring
surgical treatment.8 Furthermore, there
was no recourse to the use of an electro-

Table 1. Summary Table of IAN Injuries During Implant Surgery With Clinical Parameters and Sensibility Recovery Period
Time of Sensibility Distance
Recovery from Alveolar Length Middle
Implants Position Treatment (Month 6 DS) Nerve, mm Implant, mm
(,1 mm) no contact 62 51 molar, 11 premolar Full up 1 6 0.3 10 6 0.4 11 6 0.4
Contact without 12 11 molar, 1 premolar Removed implant 1.5 6 0.3 9 6 0.6 10 6 0.4
intrusion into canal
Canal intrusion 8 8 molar Implant removed 6 6 0.5 8 6 0.5 9 6 0.2
Lateral position 5 5 molar Full up 7 6 0.7 9 6 0.2 10 6 0.4
without intrusion
Lateral position with 3 3 molar Implant removed 4 6 0.5 11 6 0.3 10 6 0.4
intrusion
IAN injury by implant 5 3 molar, 2 premolar Full up 4 6 0.5 9 6 0.4 10 6 0.4
drill
Traumatic local 6 0.8 6 0.5 11 6 0.7 12 6 0.4
anesthesia
Total 101
A correct surgical planning and the control of drilling depth are critical factors for a correct site preparation in an area very close to the mental foramen and the mandibular canal.

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SCARANO ET AL
Table 2. Table Representing IAN Injury Related With the Total Number of Implants
and Average Experience of Operators
Implants
No contact (,1 mm)
Contact without intrusion into canal
Canal intrusion
Lateral position without intrusion
Lateral position with intrusion
IAN injury by implant drill
Traumatic local anesthesia
The management of injuries of IAN requires a high degree of expertise and a presurgical diagnosis competence to reduce
complications.
stimulation test. Etiological factors of
IAN injury can be classified based upon
time of incident, as intraoperative and
postoperative (Juodzbalys et al,
2011).19 Intraoperative etiological fac-
tors include mechanical, thermal, and
chemical ones. Postoperative etiologi-
cal factors consist of peri-implant infec-
tion and hematoma with subsequent
scaring and ischemia.
Radiographic examination was
essential to pinpoint the lesion location
as well as confirmation of INA injury.
Dental implant position to mandibular
canal was graded as:
1. too close (,1 mm) but no contact
(group 1);
2. contact without intrusion into
canal (group 2);
3. partial or full intrusion into man-
dibular canal (group 3);
Fig. 4. Chart representing statistics of patients with and without IAN injury (no damage ¼
97%; IAN ¼ 2.3%). Most cases are asymptomatic and they have presented no sensory
disturbances after implant treatment.
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IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017
Average Practice Experience
62 21
12 25
8 30
5 25
3 24
5 23
6 15
4. lateral position without intrusion
into canal (group 4);
5. lateral position with intrusion into
canal (group 5);
6. IAN injury by implant drill
(group 6);
7. Traumatic local anesthesia
(group 7).
All patients with IAN injury under-
went psychological consultation which
included background information,
detailed explanation, support, and real-
istic expectations from the injury treat-
ment. After consultation, a physiological
treatment was provided that included:
removal of the implant within 3 to 6 days
postsurgery when there was contact or
pressure on the mandibular canal.
Medical treatment depends on the
degree of severity of the nerve injury. In
case of mild degree of nerve injury,
5
a large dose of nonsteroidal anti-
inflammatory drug (such as 400–600
mg ibuprofen) 3 times daily for 1 week
was prescribed. In case of moderate or
severe nerve injury, a course of oral ste-
roids was prescribed. Oral dexametha-
sone 4 mg, 2 tablets AM for 3 days, and
one tablet AM for next 3 days, or oral
prednisolone 1 mg per kg per day (max-
imum 80 mg) might be prescribed.
Additionally, diuretics (torsemide, 10
mg per day, for 5 days), vasodilators
(pentoxifylline, 1200 mg per day for
10 days), and B group vitamins Acido
Alpha-lipoic, (superala 800 mg once
per day for 4 weeks), and antihistaminic
drugs (loratadine 10 mg per day) were
prescribed. If the situation improved,
a course of nerve recovery drugs was
repeated for 3 months (B-group vita-
mins, vasodilators). No additional phar-
macologic agents were used.
Statistical Analysis
The association of depth of bone
above the mandibular canal, length of
the implant, mandibular premolar
region and molar region, years of
experience of the operator and type of
radiographic presurgical implant and
the degree of ridge atrophy on the
incidence of altered sensation were
examined with Pearson correlation co-
efficients. Multivariate analysis using
binary logistic regression was per-
formed to examine which factors, found
significant with univariate analyses,
remained as such after adjusting for
confounding effects at each time point
(10 days, 1, 3, and 6 months).
RESULTS
The follow-up of patients who
underwent mandibular implant surgery
gave the following results: 974 patients
(91.4%) did not show any altered
sensitivity after 10 days for a total of
2930 implants, while 91 patients
(8.5%), 8 men and 19 women, with
a mean age of 59.2 6 8.1 (min 46, max
65) with IAN sensory disturbances
were invited to return (Figs. 1–3). Clin-
ical examination revealed 84 intraoper-
ative and 7 postoperative patients for
a total 95 implants (Table 1).
Clinical and radiographic exami-
nations revealed: that 62 implants were
6 NEUROSENSORY DISTURBANCE
Fig. 5. Chart with statistic nervous sensitivity recovering. No cases of persistence of anes-
thesia or serious hypoesthesia at 13 months.
too close to the nerve (,1 mm) but
without contact; 12 implants were in
contact without intrusion into the canal;
8 implants were in partial or full intru-
sion into the mandibular canal; 5 im-
plants in lateral position without
intrusion into the canal; 3 implants were
laterally with intrusion into the canal; 5
patients presented IAN injury by
implant drill (Table 2). Only implants
with partial or full intrusion into the
mandibular canal (8 implants) and im-
plants laterally positioned with intru-
sion into the canal (5 implants) were
removed for a total of 13 implants
(Fig. 4). In other patents implants were
left in situ to osseointegrate because
there was no identified possible implant
drilling or implant in the canal mandib-
ular canal. In 6 patients, a traumatic
local anesthesia was reported.
All IAN injuries occurred in second
mandibular premolar and molar dental
segments. One month later 43 patients
(47.3% of the patients referring sensitiv-
ity disturbance) had a return of sensitiv-
ity. At 3 months, another 36 patients
(39.6% of the patients referring sensitiv-
ity disturbance) had no further problems.
Of the remaining 12 patients (13.2% of
the patients referring sensitivity distur-
bance) still referred loss of sensitivity 6
months after surgery, though it was
completely recovered within 13 months
after surgery. From a clinical point of-
view, the lesions produced occurred in all
cases with alterations of the sensitivity of
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the lower lip, but never with the onset of
pain. From these sensitivity disturbance,
no problems of speech, chewing, or
swallowing were derived, or any prob-
lems concerning soft tissue biting. There
were no cases of persistence of anesthe-
sia or serious hypoesthesia more than 6
months, no cases of pain that lasted for
more than 6 to 8 weeks. The median time
of sensibility recovery is described
ine Figure 5. The patients without IAN
injury had a distance between implant
and IAN of 3 mm in 1933 Implants;
2 mm in 622 implants; 1 mm in 351 im-
plants; in contact without intrusion into
the canal in 23 implants; lateral position
without intrusion into canal in 1 implant.
Statistical Evaluation
No statistical difference was found
between the depth of bone above the
mandibular canal, length of the implant,
mandibular premolar and molar region,
age of experience of the operator nor the
degree of ridge atrophy and the inci-
dence of altered sensation (P # 0.05). A
statistical difference was observed
between type of preimplant surgery
radiography used for evaluation of the
depth and thickness of the alveolar bone
(P $ 0.05).
DISCUSSION
The increase in the use of implants
coincides with an increase in IAN injury
complications being reported.20,21 In
SCARANO ET AL
the present study no correlation was
observed between the depth of bone
above the mandibular canal, length of
the implant, the mandibular premolar
and molar region, the years of experi-
ence of the operator nor type of preim-
plant surgery radiography, nor the
degree of ridge atrophy and the inci-
dence of altered sensation, but it was
observed that many cases of IAN injury
had been evaluated only with a dental
panoramic X-ray, only 3 cases were
observed with a preoperative examina-
tion with CT or CBCT for dental im-
plants in the alveolar canal. From the
results observed in the present study,
the correct planning of the implant inser-
tion constitutes an important step for the
reduction of nerve complications in
implant prosthetic rehabilitations. Some
dental and surgical practices require
exposure of the nerve trunks with the
risk of intraoperative injury. For this rea-
son it is advisable to strictly observe the
following protocols:
1. complete medical work-up result-
ing in a careful examination of the
intra- and extraoral condition
2. study models of the dental arches
3. a dossier comprising an OPT
x-ray and possibly a CT scan
4. complete laboratory analysis
5. photographic documentation
6. a detailed treatment plan; precise
operative radiographs; control
photographs.
The accidental injury of IAN by
instruments during the preparation of
the implant site is deemed unacceptable
in medico-legal cases, especially when
either the right technical procedures
with the adjacent anatomical structures
and/or the preliminary diagnostic-
prognostic assessment protocols have
not been observed. It is therefore crucial
to always make the most detailed x-ray
analysis of the case in order to avoid
these inconveniences. The prevention
of iatrogenic injury is the first objective
to be pursued and realized with proper
planning of the intervention, based on
a careful radiographic study of the local
regional areas, and by adopting suitable
measures of surgical technique, de-
signed to preserve the integrity of the
nerve structures.
SCARANO ET AL
The CT scan is considered the first
choice for the planning of implant
surgery in the posterior-inferior sec-
tors.22 The tomographic technique, in
fact, determines the thickness and the
available vestibule-oral bone height, that
is the distance between the top ridge and
the mandibular canal or the emergence
of the chin, it is essential in the choice of
length and position of the dental implant.
The use of a CT scan is also indicated to
plan implant insertion in the interforami-
nal area close to the mental foramen, as
radiographic evaluation performed with
only conventional techniques does not
display the anterior ramus of the nerve
which, before exiting the jaw, curves
upward, outward and distally.
Truncular anesthesia to the Spix
spine represents the first operative risk
for both the lingual and inferior alveolar
nerves, likely to be lesioned as a result of
accidental puncture.23 The realization of
a muco-periosteal flap in the posterior
region of the mandible increases the risk
of a neurologic injury during incision of
that blunt dissection. To avoid involving
the mental nerve it is advisable to carry
out the dissection elsewhere, by the
emergence in the mesial or distal ipsilat-
eral position of the neurovascular bun-
dle, in respect to the homolateral canine,
or distally from the second premolar,
and proceed with the initial mobiliza-
tion of muco-periosteal tissue by blunt
dissection.
Implant recipient site preparation,
especially if carried out in the immedi-
ate vicinity of the mental foramen and
the mandibular canal, although care-
fully planned through radiological eval-
uation, requires continuous monitoring
of the drilling depth, which is carried
out by visual inspection of the reference
notches in millimeter engraved on both
the drills and probes provided by the
manufacturers. The approach of the
rotating instruments in the mandibular
canal cannot be detected, when the
infiltration anesthesia has been per-
formed, rather than the loco-regional
block of the inferior alveolar nerve, on
the basis of painful sensations experi-
enced by the patient, because the
response to a specific stimulation is
remarkably variable among individuals
and is conditioned by the subject’s
interpretation.
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IMPLANT DENTISTRY / VOLUME 26, NUMBER 5 2017
The diagnosis of nerve injury is
fundamentally done at an early stage,
immediately after the occurrence of
damage and at a later, more complex,
and articulated stage, which requires
specific surveys. In fact the methods
used for the diagnosis of nerve injury
cannot be used immediately after injury
occurs but only when the effect of the
anesthetic has passed, especially the
subjective methods since they are based
on the patient’s evaluation of his/her
own sensation.
The early phase consists essentially
in the assessment of symptoms reported
by the patient (anesthesia, hypoesthe-
sia, paresthesia, dysesthesia, ageusia or
hypogeusia) and leads to an orthopan-
tomographic examination in search of
correlated pathological changes, such
as the location of a bone fragment or
penetration of a dental implant within
the mandibular canal.
The absence of an objective radio-
graphic finding and the clinical symp-
toms of paresthesia and/or hypoesthesia,
especially in the area of the inferior
alveolar nerve innervation lead to a diag-
nosis of a nerve “stupor” syndrome (neu-
rapraxia), suggesting an attitude of
watchful waiting. Instead, in the case
of an intraoperative lesion and/or symp-
toms of a persistent, pejorative nature, it
is necessary to investigate further, with
clinical and instrumental testing.24–26
In the case of injury to the inferior
alveolar nerve, clinical trials involve
mechanoceptive, chemical and thermal
evaluation, electrical stimulation and
nociceptive discrimination, and should
be repeated on a monthly basis starting
the first month after the accidental
trauma, in order to monitor the func-
tional evolution of the affected nerve.
The area innervated by the inferior
alveolar nerve, represented by the lower
region of the face, seems to be partic-
ularly sensitive to spatial variations and
not very sensitive to heat and 2-point
discrimination; therefore, during the
mapping of the nerve, that is, the
demarcation with pencil or marker of
the area of dermal sensory deficit the
highlighted surfaces will present a dif-
ferent extension depending on the type
of sensitivity examined.27
Instrumental testing includes
electrophysiological analysis, such
7
as somatosensory-evoked potential
and blink reflex, and advanced tech-
niques in diagnostic imaging, such as
CT and magnetic resonance imaging.
The treatment of damaged nerve
trunks follows a different regimen,
medical or surgical, depending on
the extent of pathological changes
and neurological symptoms reported
by the patient.
Medical therapy differs according to
the different stages of wound healing: the
initial phase, immediately after the trau-
matic event, the reparative phase, within
the first month, the late phase, in which
the neurological symptoms stabilize.
During the first period the adminis-
tration of drug combinations, consisting
of NSAIDs, corticosteroids, proteolytic
enzymes, vitamins and antibiotics are
suggested, with the aim of reducing the
compression on the nerve trunk from
edema or hematoma and to prevent the
development of infections and hinder
the growth of scar tissue. In particular,
steroids act as antiedema factors, favor-
ing the decompression of the lesion, in
synergy with the proteolytic enzymes
which are characterized by intense fibri-
nolytic activity and are responsible for
the lysis of the clot, and they promote the
resorption of the hematoma. The use of
high-dose vitamin concentrates (3–4 g/d
of vitamin C, 1500–2000 UI/d of vita-
min E) protects the vascular structures
of the affected nerve and prevents
post-traumatic ischemia, limiting cellu-
lar damage.28
In the reparative phase, drug treat-
ment includes hormones, vitamins, vas-
odilators and ozone to promote nerve
regeneration. During this phase, in
association with drug treatment, phys-
ical therapy with magnetic therapy,
which involves the use of a magnetic
field capable of modulating the activity
of ionized molecules in ischemic areas,
are beneficial.
The use of drugs during the late
phase is indicated in case of failure of
the treatment regimens described above
and used to control the pain of central
origin induced by the cortical hyperac-
tivity syndrome (deafferentation). To
prevent this, the administration of anti-
convulsant agents, such as carbamaze-
pine, diphenyl-hydantoin and valproic
acid, and associations of tricyclic
8 NEUROSENSORY DISTURBANCE
antidepressants and psychotropic
agents (phenothiazine) are suggested,
and analgesics gel applied locally, to
reduce the conduction of nociceptive
stimuli from the site of the lesion to the
central nervous system, would be able
to prevent or at least delay the onset of
the pain of central origin.8
Surgical therapy (microneurosur-
gery) is aimed at restoring the conti-
nuity of the nerve function or at least
to improve the patient’s symptoms,
reducing anesthesia, paresthesia or
dysesthesia to an acceptable degree
of hypoesthesia.
Scientific literature reports essen-
tially 3 techniques for surgical resolu-
tion of the lesions: neurorrhaphy or
end-to-end anastomosis by direct epi-
neural or interfascicular suture; autol-
ogous nerve tissue graft taken from
various locations; intubation of the
nerve stumps or tubulization.
Considering the serious debilitat-
ing effects resulting from a lesion of the
IAN and the complexity of the thera-
peutic diagnostic protocols, the patient
should be informed of the risks of the
treatment regarding possible nerve
damage. These are the basic require-
ments, along with, of course, a sufficient
diagnostic preparation and a good level
of communication between operator
and patient. Surgery in cases of injuries
of IAN should be performed by person-
nel with a high degree of professional-
ism and a presurgical evaluation with
CBCT to minimize morbidity and
complications.
CONCLUSION
According to the results of our
data analysis, the IAN lesion is rare
and reversible in most clinical cases.
The outcomes of the present study
also emphasizes the importance of
treatment planning in the prevention
of implant-related nerve injuries
and the importance of preoperative
radiographic planning with CBCT
imaging.
DISCLOSURE
The authors state that there is no
conflict of interest, and declare that no
benefit of any kind will be received
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
either directly or indirectly by the
authors.
APPROVAL
This study was performed follow-
ing the principles of the Declaration of
Helsinki regarding research on humans;
signature of a written informed consent
form all patients was requested and
obtained. The study was approved by
the Inter Institutional Ethics Committee
of University of Chieti-Pescara, Chieti,
Italy (No. 3346).
ROLES/CONTRIBUTIONS
BY AUTHORS
Antonio Scarano, MD, DDS:
Wrote the paper. Bruna Sinjari, DDS:
Performed data collection. Giovanna
Murmura, DDS: Performed data col-
lection. Felice Lorusso, DDS: Per-
formed data analysis.
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Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.