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Trigeminal Neuralgia Oral Surgery
Trigeminal Neuralgia Oral Surgery
N EU RA L GI A
Introduction
Definition
Historical review of trigeminal neuralgia
Tic douloureux
Aetiology
Pathogenesis
General characteristics
Clinical characteristics
Diagnosis
Treatment modalities
Management
INTRODUCTION:
It is the most debilitating form of neuralgia that
affects the sensory branches of the Vth cranial
nerve.
DEFINITION:
It is defined as sudden, usually
unilateral, severe, brief, stabbing,
lancinating, recurring pain in the
distribution of one or more branches of
the Vth cranial nerve.
HISTORICAL REVIEW OF
TRIGEMINAL NEURALGIA:
JOHN LOCKE in 1677 gave the first full description
with its treatment.
NICHOLAS ANDRE in 1756 coined the term Tic
Doloureux.
JOHN FOTHERGILL in 1773 published detailed
description of trigeminal neuralgia.
TIC
DOULOUREUX:
Tic douloureux
painful jerking
AETIOLOGY:
Usually idiopathic
Demylination of the nerve
Multiple sclerosis
Petrous ridge compression
Post traumatic neuralgia
Intracranial tumours
Intracranial vascular abnormalities
Viral etiology
PATHOGENESIS:
GENERAL CHARACTERISTICS:
Incidence:
8 : 1,00,000
Age:
Sex:
Division of trigeminal
nerve involvement:
V3 > V2 > V1
CLINICAL CHARACTERISTICS:
Manifests as a sudden, unilateral, intermittent
paroxysmal, sharp, shooting, lancinating, shock like
pain, elicited by slight touching superficial trigger
points which radiates from that point, across the
distribution of one or more branches of the
trigeminal nerve.
Pain is usually confined to one part of one division of
trigeminal nerve.
Pain rarely crosses the midline.
Attacks do not occur during sleep.
Cutaneous
Intraoral
Teeth
Cheek
Gingivae
Tongue
Lateral brow
DIAGNOSIS:
TREATMENT MODALITIES:
MEDICAL
SURGICAL
MEDICAL MANAGEMENT:
It is the first line approach for most of the patients.
CARBAMAZEPINE:
Trade name: Tegretol
Carbitrol
Dosage:
PHENYTOIN:
It is usually used in conjunction with carbamazepine.
Trade name: Dilantin
Dosage:
GABAPENTIN:
It is more expensive than other drugs but has a less
side effects.
BACLOFEN:
It is a GABA agonists.
These drugs reduces the central projection painful
afferent impulses.
Trade name: Lioresal
Dosage:
10 mg (tds)
TRICYCLINE ANTIDEPRESSANTS:
Amitriptyline
10 300 mg/day
Doxepin
10 300 mg/day
Nortriptyline
10 150 mg/day
Imipramine
10 300 mg/day
SURGICAL MANAGEMENT:
PERIPHERAL INJECTION:
It has been known that injection of destructive
substance into peripheral branches of the trigeminal
nerve, produces anaesthesia in the trigger zones or
in areas of distribution of spontaneous pain.
(A) LONG ACTING ANAESTHETIC AGENTS:
Without adrenaline such as bupivacaine with or
without corticosteroids may be injected at the
most proximal possible nerve site.
Disadvantage:
May produce
full anaesthesia
deep hypoesthesia
INFRAORBITAL NEURECTOMY:
(i) Conventional intraoral approach
(ii)Brauns transantral approach
Conventional intraoral approach:
A U - shaped Caldwell Luc incision is made
in the upper buccal vestibule in the canine
fossa region.
Mucoperiosteal flap is reflected superiorly to
locate the infraorbital foramen.
Once the nerve is exposed, all the peripheral
branches are held with the hemostat &
avulsed from the skin surface intra orally.
LINGUAL NEURECTOMY:
An incision is made in the anterior border of
the ramus slightly towards the lingual side.
The lingual aspect is exposed & the lingual
nerve identified in the third molar region just
below the periosteum.
The nerve can be either
avulsed or ligated, cut
and the ends may
be cauterized.
CRYOTHERAPHY:
Barnard first used cryotheraphy in 1981 for
the treatment of the trigeminal neuralgia.
After identifying the affected nerve , it is
then exposed to the cryoprobe intraorally.
Direct application of cryotheraphy probe at
temperatures colder than -60 C are known to
produce Wallerian degeneration without
destroying the nerve sheath itself.
Nerve is exposed for 2 mm freeze followed
by 5 mm thaw cycle.
The freeze thaw cycle is repeated at least 3
times.
Indication:
Toxicity of drugs
Failure of response to the other modalities
Dependence on the drugs for life time.
Elderly patients
Medically compromised patients
Advantages:
Comparative low rate of recurrence
Zero mortality
Thermocoagulation preserves the motor
function of the trigeminal nerve
Can avoid major surgical procedure
Disadvantage:
May cause
anaesthesia dolorosa
loss of corneal reflex
Meningitis (rarely)
Advantages:
Simple technique
Lower incidence
of anaesthesia
dolorosa
Complication:
Post operative headache, nausea, vomiting
Meningitis
Post operative herpes simplex perioralis
A compressing branch of
the superior cerebellar
artery will be seen
medial to the nerve at
the root entry zone.
Non absorbable
insulating sponge may
also be placed.