Presented by

Cathrine Diana

PG I
Dept of oral and
maxillofacial
surgery
Cellular component:
 Neurons- cell body &
axon
 Schwann cells

 Connective tissue

 Epineurium

 Perineurium

 endoneurium
 Cranial - Motor, sensory, mixed
 Spinal nerves – sympathetic , parasympathetic
 Myelinated , non myeliniated

 Nerve fibres:
 A - alpha – largest fibre, fastest conduction, fine
touch , position
 A-beta – proprioception
 A – delta – sharp pain , fast
 C fibres – slow pain
 Classification of nerve injury is based on
 the damage sustained by the nerve
components,
 nerve functionality, and

 the ability for spontaneous

recovery
 Etiologic
 Seddon’s
 Sunderlands
 Anatomic
 Samii’s
 Histological
 Based on onset(time)
 Mechanical injury
 Crush/Compression injury

 Laceration

 Stretch

 High velocity trauma

 Cold injury

 Iatrogenic

 infectious
Grade VI – complex peripheral nerve
injury
Degree of nerve Spontaneour Rate of recovery Surgery
injury recovery
First neuropraxia Full Days to 3 months none
Second full Regenerates at the none
axonotmesis rate of
1mm/month
third partial Regenerates at the None/
rate of neurolysis
1mm/month
fourth none Following surgery Nerve repair,graft
at the rate of or transfer
1mm/month
Fifth none Following surgery Nerve repair,graft
neurotmesis at the rate of or transfer
1mm/month
Sixth –mixed Recovery &type of surgery vary depends on combination
injury of degrees of injury
 Paralysis- loss of motor function
 Paresis – incomplete loss of motor function
 Anesthesia – loss of all sensation
 Hyperesthesia – excessive sensation
 Hypoesthesia – diminished sensation
 Hyperalgia- excessive sensitivity to painful stimuli
 Hypoalgesia – lowered pain sensitivity
 IAN - injured in case of mandibular fractures and
ORIF, tooth extraction, injection,orthognathic
surgeries,minor surgical procedures.
 Lingualnerve – most commonly in third molar
extraction,
 Mental N- fracture of mandible, genioplasty,
minor surgical procedures, abnormal
pressure from denture

 Infra orbital N – fracture of infra orbital rim

 ASA/ PSA - osteotomy of maxilla, apicoectomy

 Facial N- penetrating injury, parotid surgeries,

TMJ surgeries

 Auriculo temporal N- TMJ surgeries

 Segmental demyelination: it is the selective
dissolution of the myelin sheath segment &
is characterized by slowing of conduction
velocity as nerve impulses travel along the
de
 associated with minor neuropraxia injury of
axons.
 It is a process that results when a nerve fibre is cut
or crushed, in which the part of the axon separated
from the neuron's cell body degenerates distal to
the injury. This is also known as anterograde or
orthograde degeneration
Some times wallerian degeneration begins in the
most peripheral tissue and progress centrally from
that point – common in trigeminal system caused by
metabolic intoxication like metal poisoning, isoniazid
and penicillin therapy
 If the tissue deinnervated for a long period of time
, certain clinical changes may take place, which are
called as neurotophic effect.
 Skeletal muscles – early spontaneous muscle
spasm, flaccid paralysis,with progressive atrophy
and lack of muscle definition and tone.
 Skin & mucosa –cold, dry and inelastic,
susceptibility to injury, poor healing, irregular
keratinization, scaly , cracked skin.
Classic physical and occupational therapy:
 Like lubrication, protection of surface tissue from
trauma, manual stimulation of glandular tissue,
warming and temperature control, electric
stimulation of intact motor neuron
 Starts at the coaptation site .
 In ideal suituation after injury,
clearance of debris
(by macropages & schwann cells)

spourtings from proximal axon

growth cones by cell elongation

 secreation of neurotropic factors 7
folds in 14 days
NGF,BDNF,GDNF
(schwann cells in distal basal lamina)

attraction of GC towardsneurotropic
gradient

guided by formation of fibroblast & collagen

matrix

Migration of schwann cell formation

of band of bungner
 interaction of axon with CAM

Functional reconnection with target at basal

lamina
 The thin nerve fibres will then gradually
thickened to their original diameter,and the
investing schwann cell form the myelin
sheath.
 Provocation test of regeneration of nerve
sprouts. Light palpation over suspected area
of injury, produce distal referred tingling
sensation at the target site. – indicate small
nerve fibre recovery. But poorly correlate with
functional recovery, may confused wit
neuroma formation
 The growing axonal sprouts may be
inhibited by the scar tissue / foreign bodies
which act as a barrier. When this happen
the growth cone proliferate as aimless
tumour along with the fibrous tissue to
form a tumour called neuroma.
Amputation neuroma:
 Neuroma
incontinuity :
 neuroma along the nerve line – may produce
artificial synapses
 Leads to abnormal chain reaction to original
stimuli. This may be a common
explaination for trigeminal ost
neuralgia,&
traumaticp
casualgia.
 Lateral adhesive neuroma
 Lateral exophytic neuroma
 Anaesthesia dolorosa -it is a constant
boring penetrating or grinding pain in the
distribution of numbness .
 Triggered tick like neuralgiform pain:
 some case with in first week after nerve injury, pt
may experience stabbing , flashing pain
secondary to mechanical irritation/ inflammation
in the still intact nerve trunk.
 Peripheral microneurosurgery is effective in pt
with neuromas, pharmacological therapy are
most appropriate in cases of central
neuropathology
 means burning sensation
 pain begins at least 2 weeks after penetrating
missile inury in mixed peripheral nerves, region
 due to the artificial synapse of demyelinated
somatic sensory nerve segment with
unmyelinated efferent sympathetic fibre
 sense of awareness of missing body part
after amputation is called phantom
phenomenon.
 Paroxysomal stabbing , itching deep
burning of missing part appx 10 mins of
duration. Triggered by tactile sensation
 1.Clinical neurosensory testing
 Level A,B,C
 2.McGill pain questionnaire
 3.Visual analogue scale
 4.Electrophysiological testing:
 EMG
 SSEP
 NCS
 5. MRN
 Subjective assessment : visual analogue scale

 Objective assessment:
 Level A : static two point
discrimination brush stroke
directional
discrimination
 Level B : contact detection

 Level C: pin prick nociception, thermal

discrimination
 treatment

Non surgical surgical

 Local anaesthesia - EMLA

 Analgesics-The use of analgesics can help patients control

pain

 Anticonvulsants –now a days carbamazepine is the drug of

choice 200- 800 mg/ day

 Corticosteroids – reduce the inflammation

 Narcotic analgesia

 Muscle relaxant

 Tranquilizers – benzodiazepienes used in chronic pain

 Antidepressents
Evaluation of Closed Injury
 Neurolysis is performed on intra-neural and
extra-neural scar tissue to release
regenerating nerve fibres in the hope of
improving functional recovery
 External
 Internal
It is the process of nerve
decompression.
Microdissection of nerve
involves liberation of
nerve from the
surrounding scar tissue
, fixation of fracture
segment
Done under magnification 4X
& 8X

turnover epineural sheath tube in primary repair of

peripheral nerves. Ann Plast Surg. 2002 Apr;48(4):392-400
Yavuzer R1esAyhan S (Latifoğlu Ox8Atabay K
 Indicated in case of incomplete return of normal
sensory function of previously injured nerve. Under
magnification,12x/ 16x epineurium dissected
longitudinally to release the adhesion around or
within the fascicles
 Epifascicular epineurotomy
 Epifascicular epineurectomy
 Inter fascicular epinuerectomy
 Goals of Primary nerve repair < 1
wk
 Proper coaptation
 Vascularity
 Free of tension
 Failure to perform primary repair
 Late Repair > 1 wk

 Crush injury
 Glial scars
Astrocytes form a barrier preventing further
growth by forming gap junctions
 Tension in the rejoined nerve
 Anastomosis of proximal and distal nerve
ending
 Epineurial

 Fascicular

 Perineuial
 adequate exposure
 Proper anesthesia
 Magnification with loupes 8x- 10 x
 The nerve ends are then sharply transected
perpendicular to the long axis.
 Minimum of two epineural sutures with
8-0/ 9-0 nylon 180° to each other.
 Careful alignment is the critical factor in
this first step
 Perineurialrepair involves the individual
fascicles and placing sutures through
the
perineurium, protective sheath

the surrounding
fascicles

 Drawback:
 Trauma to nerve
 Fibrosis
 Tissue reaction
 Least accessible fascicle – suture first
 Fewest suture as possible
 Single site of suturing
 Better coaptation & vascularity

 Less chance of mismatch & collateral axonal

micro sprouting outside epineurium.
 Reconstruction after peripheral nerve injury
may require management of segmental
defects or "gaps" in the injured nerve
 A nerve graft will be about 10 % longer than
the gap between the nerves, and the cross-
section of the nerve end will be a quite larger
than the diameter of the nerve graft to allow
for growth
 Sural nerve
 Greater auricular nerve

 Antebrachial cutaneous nerve

 Donor Nerve

Sural nerve Greater auricular Greater auricular

N cable
2.1mm 1.5 mm 3mm

Inferior alveolar 88% 63% 125%

nerve 2.4 mm

Lingual nerve 66% 47% 94%

3.2mm
 .Tension of the suture line and inadequate
preparation of the nerve stumps are the 2 leading
causes of regenerative failure across the suture site,
resulting in poor recovery of nerve function.
 The nerve graft act as a distal nerve stump, so it ll
undergo wallerian degeneration, to provide a conduit
for axon regeneration, schwann cell regeneration is
critical for this
 Need for adequate revacularisation – initially occurs
through diffusion from tissue bed reaches
supranormal in 4-5 days.
 Grafr size – in case of increased graft size , central
necrosis occurs due to increased volume of tissue
beyond perfusion

 Sensory loss, scarring and neuroma formation can

cause morbidity to the donor site of the patient the

nerve is harvested from
 Primary repair
 Interpositional grafting
 Cross facial nerve repair
 Cross over graft or split graft
 The use of allograft nerve material is
particularly appealing because of its available
quantity and lack of donor site morbidity.
 Need for prolonged immunosuppression
required to maintain Schwann cell viability
limits clinical implementation of this method.
 Various materials are used as conduits,
 Autogeneous materials – muscles , fascia, veins
collagen
 Alloplastic material –polyglycolic acid,
Polyester,PTFE , scilicone

 Used in case if the gap

is 0.5mm- 3mm
 Type of injury
 Time of surgery.

 Patient age,

 level of injury,

 mechanism of injury,

 and associated medical conditions all

influence outcome.
 evaluated by
 static 2-PD- perceived by Merkel cell,

 , moving 2-PD- Meissner corpuscle

 and pinprick. - Free nerve endings

transmit painful stimuli
 Innervation testing – monofilament testing
 Postoperative management after nerve repair
or reconstruction is aimed toward wound
healing, and re-establishing longitudinal
excursion of the nerve
 Repairs are immobilized for
approximately 3 weeks by splinting.

 Nerve Repair and Grafting in the Upper Extremity

 S. Houston Payne, Jr., MD
 J South Orthop Assoc. 2001;10(2)
 Sensory re-education is designed to help
the patient recognize new input in a useful
manner
 Sensory re-education is carried out in
three stages:
 desensitization, early-phase discrimination
 localization, late-phase discrimination
 tactile gnosis
 Transcutaneous nerve stimulations (TNS) –
cutaneous bipolar surface electrodes are
placed in painful regions of body &low
voltage electric current is administered.
Best results will obtained if intense of
stimulation is maintained for 1 hour daily >
3 weeks
 Coaptation of nerve tissue without suture is
appealing and would potentially eliminate the
trauma associated with traditional suturing
technique. (1) more efficient,
 (2) eliminate variables of tension due to
suture placement and technique,
 (3) improve alignment of fascicles
 The two techniques that have been most
carefully evaluated are coaptation by fibrin
glue and by laser gallium-alluminium
arsenide at 820 nm wavelength
 Aiding with growth factors –
N-acetylmuramyl-L- alanyl-D-isoglutamine

 Stem cells

 Cell therapy
 Frozen nerve repair
 Metabolic manipulations using electric fields –
pulsatingneurite growth
include growth factors to influence
 Vascularized nerves can be useful to repair nerves longer than
8 cm and grafts placed in poor vascular beds that are heavily
scarred

 Microsurgery 989;10(3):220-5.
 Sciatic nerve regeneration in the rat. Validity of walking track assessment in
the presence of chronic contractures.
Dellon AL1, Mackinnon SE
Immediate primary repair in sharp injuries
with suspected transsection of nerve because
delay leads not only to retraction but also to
severe scaring

 Bluntly transsected nerve best repaired after

a delay of several weeks.

 A focally injured nerve should be explored if no

functional return within 8-10 weeks

 Decision - making as to whether neurolysis or

resection & repair in a lesion in gross continuity

based on intraoperative electrophysiological

evaluation

 Split repair with usually graft – lesion in

continuity

,partial function or undergoing partial regeneration

 Careful patient selection for operation
 Nerve anastomosis failure
 ① inadequate resection of scarred nerve
ends
 ② nerve suture distration
 A good end result requiring rehabilitation
from onset of treatment.
 Prevention of disuse, relief of pain,
predicting probable end results of operative
procedures
  References:

 Peterson’s principle of oral &maxillofacial surgery 2nd edt

 Text book of Oral and maxilla facial surgery – Gustav kruger 6th edt

 Nerve injury and repair – sussan E mackinnon, Washington university school of

medicine

 Peripheral nerve injuries anr repair – Adam osbourn – review of surgeries

 turnover epineural sheath tube in primary repair of peripheral nerves. Ann Plast

Surg. 2002 Apr;48(4):392-400

 Nerve Repair and Grafting in the Upper Extremity S. Houston Payne, Jr., MD J
South Orthop Assoc. 2001;10(2)

 Static and dynamic repairs of fascial nerve injury -Hillary White, Eben
Rosenthal-
oral & maxillofacial surgery clinics of north America 25(2013) 303- 312

 Lingual nerve repair to graft or not? Michael millaro DMD et al YJOMS

Thank
you