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Significant association between several risk factors and Inferior alveolar nerve problems after third molar extraction

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The incidence reported in the literature ranges from 0.4-8.4%third molars and in some instances the damage can be permanent. The aim of this case-control study was to investigate the specific risk factors for neurosensory deficits of inferior alveolar nerve (IAN) after third molar extraction.

The cases consisted of patients showing neurosensory deficits of the lower lip and mental area after mandibular third molar extraction. The control group consisted of randomly selected patients who had undergone third molar extraction without any subsequent neurosensory symptoms after the procedure.  The authors considered a number of predictor variables grouped as demographic, radiographic, and anatomic. The radiographic variables included the impaction depth and angulation of the mandibular third molar. The impaction depth was classified according to the Pell-Gregory classification angulation was classified according to the Winter’s classification. The anatomic variable, were classified according to the Rood and Shehab 7-type classification. The area of paraesthesia was recorded clinically using 2-point discrimination, pin- prick test, and light touch detection, using Semmes- Weinstein monofilaments. Recovery was assessed as decreases in area with dysaesthesia and a complete disappearance and a decrease in discomfort or no additional visits

  • 104 cases and 135 controls were included
  • Older age and deeper impaction status were significant risk factors (P < .05). Darkening of the roots, deflection of the roots, narrowing of the roots, dark and bifid apexes of the roots, and narrowing of the canal were also significant risk factors.
Odds Ratio95% CI P Value Positive predictive valueNegative predictive value
Darkening of the roots1.32

0.8-2.2.286
0.999.3
Deflection of the roots2.68*1.1-6.6.032*1.999.3
Narrowing of the roots10.34* 2.3-46.6.002*6.999.3
Dark and bifid apex of the roots1.94 0.8-4.6.1281.599.2
Interruption of cortical line of canal 0.710.4-1.2.1910.799.1
Diversion of the canal4.81* 1.8-12.5.001*3.299.3
Narrowing of the canal7.54*3.0–19.1.000*4.699.4

* Statistically significant

  • However, the relatively low positive predictive value renders questionable the predictability of superimposition signs on orthopantomography. In the absence of specific radiographic signs, the risk of neurosensory deficit of the IAN could be negligible.
  • The sensory symptoms disappeared after 6 months in 92.3% of the patients and 98.1% showed recovery after 1 year.

The authors concluded

The results of the present study have demonstrated a significant association between several risk factors and neurosensory deficits of the IAN after third molar extraction.

Links

Kim JW, Cha IH, Kim SJ, Kim MR. Which Risk Factors Are Associated With Neurosensory Deficits of Inferior Alveolar Nerve After Mandibular Third Molar Extraction? J Oral Maxillofac Surg. 2012 Aug 15. [Epub ahead of print] PubMed PMID: 22901857

 

 

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Little evidence available on treatments for iatrogenic injury to inferior alveolar or lingual nerves

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The lingual and inferior alveolar nerves are potential at risk of damage during some oral and maxillofacial surgery procedures. Fortunately the majority are temporary, with resolution taking place within 8 weeks.  Injuries of 6 moths or greater are considered permanent and a range of techniques have used.   The aim of this review was to evaluate the effects of different interventions and timings of interventions to treat iatrogenic injury of the inferior alveolar or lingual nerves.

Searches were conducted in the Cochrane Oral Health Group’s Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase databases with no restrictions on the language or date of publication.  Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as sequelae of iatrogenic injury. Standard Cochrane methodological procedures were followed.

  • Two studies that evaluated a total of 26 patients were included.
  • Both studies were considered to be at high risk of bias.
  • Patient-reported altered sensation was partially reported in one study and fully reported in another.
  • Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low; the outcome data were fully reported in one small study of 13 patients, with differential drop-out in the control group, and patients suffered only partial loss of sensation.
  • No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating or speaking or taste.
  • No studies reported on quality of life or adverse events.
  • The overall quality of the evidence was very low as a result of limitations in the conduct and reporting of the studies, indirectness of the evidence and the imprecision of the results.

The authors concluded

There is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient-focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment.

Comment

This Cochrane review lists a wide range of reported interventions for treating iatrogenic nerve damage:-

  • Surgical intervention.
    • External neurolysis:
    • Internal neurolysis:
    • Neurorrhaphy:
    • Neuroma excision:
    • Autologous nerve grafting:
    • Tubulization:
  • Laser treatment.
  • Medical treatment.
  • Counselling.

However their detailed searches could only find two RCTs evaluating low-level laser treatment in a small number of patients. Consequently, as the authors suggest there is much work required to reduce or prevent initial damage and to recognise and support those patient who do suffer these injuries. In addition high quality RCTs need to be conducted to identify the most effective procedures.

Links

Coulthard P, Kushnerev E, Yates JM, Walsh T, Patel N, Bailey E, Renton TF. Interventions for iatrogenic inferior alveolar and lingual nerve injury. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD005293. DOI: 10.1002/14651858.CD005293.pub2.

 

 

 

 

 

 

 

 

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Nerve repositioning for implant placement: neurosensory complications common

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While the use of dental implants has increased in cases where there is a limited mandibular height the options are, short implants, bone grafting and inferior alveolar nerve (IAN) repositioning. IAN repositioning is performed via one of two surgical techniques, lateralisation or transposition, with lateralisation yielding lower degrees of nerve deficiency. The aim of this review was to identify the complications associated with IAN repositioning.

Methods

Searches were conducted in Medline, the Cochrane Library and Scopus databases. English language studies (case report, case series, prospective and/or retrospective clinical studies) reporting IAN repositioning for rehabilitation with osseointegrated implants were considered.   Three reviewers carried out study selection and study quality was assessed.

Results

  • 24 studies were included. Only 1 was considered to be at low risk of bias, 2 at moderate risk and 21 at high risk.
  • 15 studies considered transposition, 7 considered lateralisation and 2 considered both. A summary of the findings is shown in the table below.
  • The longest mean follow-up time was 49.1 months; at the end of follow-up, 7% of the patients (1/15) still experienced neurosensory disturbances.
  • The shortest mean follow-up time was 6 months, with full neurosensory recovery of the entire sample population.
Lateralisation Transposition
Number patients treated 125 150
Number with neurosensory evaluation 123 146
Initial sensory disturbance 95.9% (118/123) 58.9% (86/146)
Sensory disturbance end of follow up 3.4%   (4/118) 22.1% (19/86)

Conclusions

The authors concluded

The high level of bias associated with the literature included in this review and the increasing number of posterior mandible atrophy cases worldwide, show the necessity of greater data consolidation to determine scientifically if and when the IAN repositioning technique can be recommended,

Commentary

The growing use of dental implants for the rehabilitation of edentulous jaws is leading to greater exploration of their use with increasing use of procedures such as sinus lifts, bone graft and IAN repositioning to enable use of the standard length implant. As shown by this review which has focused on what for some will be the most obvious complication of nerve repositioning, that of neurosensory deficit. Other issues such as whether the technique recovers the alveolar ridge anatomy, or increases fractures are not addressed by the included studies although mentioned in the discussion. Whether this type of more heroic procedure to enable standard implants becomes a more common procedure should depend on more information on the complications from larger and better conducted studies.

Links

Vetromilla BM, Moura LB, Sonego CL, Torriani MA, Chagas OL Jr. Complications associated with inferior alveolar nerve repositioning for dental implant placement: a systematic review. Int J Oral Maxillofac Surg. 2014 Aug 12. pii: S0901-5027(14)00260-4. doi: 10.1016/j.ijom.2014.07.010. [Epub ahead of print] Review. PubMed PMID: 25128261.

 

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Inferior alveolar nerve injury following bilateral sagittal split osteotomy lacks standardised assessment procedures and reporting says review

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Bilateral sagittal split osteotomy (BSSO) is a commonly used for treating mandibular deformity. As it is performed in close proximity to the inferior alveolar nerve (IAN) there is frequently nerve damage. IAN damage at operation has been reported to vary from 1.3-18% with postoperative disturbances ranging from 9-85%.

The aim of this review was to review the reported incidence of inferior alveolar nerve injury after orthognathic surgery and to assess the methods used to evaluate IAN sensory disturbances in reports published between 1990 and 2013.

Methods

Searches were conducted in the Medline, Web of Knowledge, OneFile, and online plat- forms of various publishers. Two reviewers carried out study selection independently. Randomised, non-randomised clinical trial, cohort studies, case–control studies, case reports in English were considered.

Results

  • 61 studies were included.
  • 16 studies (26.0%) did not indicate the incidence of IAN injury
  • Pre-operative status of the IAN was also not assessed in 22 reports (36.1%)
  • Only 21 studies (34.4%) provided details of the IAN assessor
  • IAN neurosensory disturbance was assessed:-
    • Subjectively in 47 papers (77.0%)
    • Objectively in only 14 of the papers (23.0%); seven of the studies used only objective method and 7 both subjective and objective methods
  • Overall incidence of IAN disturbance varied from 1.6% to 90%

Conclusions

The authors concluded

The observed wide variation in the reported incidence of inferior alveolar nerve injury is due to a lack of standardized assessment procedures and reporting. Thus, an international consensus meeting on this subject is needed in order to establish a standard-of-care method.

Commentary

The details of the search for this review were a little vague and restricted to the English language so it is possible that some relevant studies may have been missed. As IAN damage is a recognised complication of the BSSO it is strange that almost 26% of the included studies did not provide figures for incidence. The authors also note variation in the time-point at which damage is assessed and the variations between objective and subjective approaches to assessment. The authors highlight that there is no purely objected method of clinically assessing iatrogenic injury to the terminal branches of the trigeminal nerve but the BSSO was first described in 1957 so the call for standardised assessment and reporting procedures is long overdue.

Links

Agbaje JO, et al. Systematic review of the incidence of inferior alveolar nerve injury in bilateral sagittal split osteotomy and the assessment of neurosensory disturbances, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/

Dental Elf – 21st May 2012 – Insufficient trial evidence that any surgical treatment for prominent lower front teeth is better or worse than another

Dental Elf – 7th Mar 2012- Presence of mandibular third molars during sagittal split osteotomies did not increase complications

The post Inferior alveolar nerve injury following bilateral sagittal split osteotomy lacks standardised assessment procedures and reporting says review appeared first on The Dental Elf.

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