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Current management of these nerve injuries is often inadequate. Discussion usually centres on surgical correction with little or no attention to medical or counselling intervention. In part the fault rests with how such patients are assessed. There is a deficiency in functional and pain evaluation and a total focus on basic mechano-sensory evaluation which is not necessarily reflective of the patients' difficulties. A recent review of publications pertaining to trigeminal nerve repair highlights that the average time from injury to nerve exploration was 16 months – far too late to prevent central neural changes due to altered peripheral input (neuropathic pain). 13 Most importantly the management of iatrogenic nerve injuries depends upon the mechanism (LA, wisdom teeth, implant, root canal), the duration of the nerve injury and the patient's symptoms. Lingual nerve
The cost of Invisalign is dynamic, changing with each patient and practice. But the question to answer is: why does the price of Invisalign treatment fluctuate so much? It mostly comes down to these five factors. 1. Condition Complexity
To reach Diamond II, a doctor needs to accumulate 20,000 points within a given timeframe. This means that any provider who has reached this tier has significant experience with the system and has likely treated fairly complex cases. Renton T, Yilmaz Z . Managing iatrogenic trigeminal nerve injury: a case series and review of the literature. Int J Oral Maxillofac Surg. 2012 May; 41: 629–637. Lingual and inferior alveolar nerve injuries are normally closed injuries. Open sensory nerve injuries seen mainly on limbs due to trauma avail themselves to immediate exploration and repair without delay. Conversely our profession has a 'sit and wait' policy for resolution of trigeminal nerve injuries unless known section has taken place. Resolution The incidence of IAN involvement 1-7 days after surgery is around 1-5%. The incidence of persistent IAN involvement (still present after six months) varies from a high of 0.9% to a low of zero. 17 Damage to the inferior alveolar nerve, leading to persistent hypoaesthesia/dysaesthesia in its sensory distribution, is less amenable to surgical repair. The prognosis for spontaneous nerve regeneration after six months is poor. Complaints to the General Dental Council are predominantly related to implants and often involve IAN injury. Neuropathic pain can be very debilitating and when compounded by poor management may result in subsequent litigation. Litigation is often based on inadequate consent procedure, inadequate planning and assessment, causation of avoidable nerve injury and poor management of the patient once the nerve injury has occurred.
Robinson P P, Loescher A R, Smith K G . The effect of surgical technique on lingual nerve damage during lower 3rd molar removal by dental students. Eur J Dent Educ 1999; 3: 52–55. Flores A J, Lavernia C J, Owens P W . Anatomy and physiology of peripheral nerve injury and repair. Am J Orthop 2000; 29: 167–173.Renton T . Prevention of iatrogenic inferior alveolar nerve injuries in relation to dental procedures. Dent Update 2010; 37: 350–352, 354–356, 358–360, passim. If complete neural transection or severe nerve injury is suspected, the patient should be informed of the situation and the lingual or inferior alveolar nerves require immediate exploration and or nerve repair by an experienced surgeon. Surgical exploration of damaged nerves usually involves an intraoral approach and decompressions (removal of surrounding scar tissue) with gentle debridement and occasionally excision of a neuroma with good apposition of the nerve endings. Essentially we cannot 'fix' the effects of nerve injury and as with many medical conditions, the apparent normal appearance of a damaged or repaired nerve is not reflected by normal function or indeed a symptom free patient. One recent study has shown that significant improvement in nerve function can be achieved by specialist surgical investigation and repair when undertaken within three months of the injury and therefore recommends early surgical intervention. No improvement of symptoms by three months indicates that a return to normal function is unlikely and that consideration should be given to referral of the patient to a clinician with specialist interest for management of the patient usually using reassurance, education, non-surgical managements (medical pain management, counselling techniques) and rarely surgery. Inferior alveolar nerve Renton T, Hankins M, Sproate C, McGurk M . A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Br J Oral Maxillofac Surg 2005; 43: 7–12. Does the addition of cone-beam CT to panoral imaging reduce inferior dental nerve injuries resulting from third molar surgery? A systematic review Renton T, McGurk M . Valuation of factors predictive of lingual nerve injury in third molar surgery. Br J Oral Maxillofac Surg 2001; 39: 423–428.
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Zuniga J R, Pate J D, Hegtvedt A K . Regenerative organization of the trigeminal ganglion following mental nerve section and repair in the adult rat. J Comp Neurol 1990: 22: 295: 548–558.
Once IAN neuropathy develops this may be a sign of spreading bone infection related to a bone sequestrum or tooth fragments remaining in situ. Implant nerve injuriesSimon M A, Vree T B, Gielen M J, Booij M H . Comparison of the effects and disposition kinetics of Articaine and lidocaine in 20 patients undergoing intravenous regional anaesthesia during day case surgery. Pharm World Sci 1998; 20: 88–92.
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