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Background: Trigeminal trophic syndrome (TTS) is a rare condition caused by damage to the trigeminal nervous system, resulting in sensory disturbances and ulcers on the face. Treating TTS is complex and often requires medical or surgical intervention like flap reconstruction. However, there is limited research on surgical treatments for TTS ulcers., Methods: We report the case of a 19-year-old man with TTS. We employed an innovative surgical technique involving dual cross-face nerve grafts. In the initial procedure, corneal neuralization was accomplished using supraorbital and cross-face infraorbital nerve graft. The subsequent operation utilized auricular composite tissue flap transplantation repair and cross-face mental nerve graft., Results: This procedure led to rapid and sustained healing, as well as aesthetic improvement., Conclusion: Cross-face nerve grafts is a promising tool in the treatment of refractory ulcers caused by diseases such as TTS., (© 2024 Wiley Periodicals LLC.)

Purpose: Our primary objective was to assess the efficacy of allogeneic nerve grafts in inferior alveolar nerve or lingual nerve repair. We hypothesized that using allogeneic nerve grafts would be effective, as evidenced by achieving high rates of functional sensory recovery (FSR). Additionally, we looked if sex, time from injury to repair, etiology of nerve damage, and graft length affected outcomes., Methods: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. PubMed and Scopus databases were searched using specific search strategies to generate eligible studies. Inclusion criteria encompassed studies reporting use of allogeneic grafts, assessing FSR using either Medical Research Council Scale or Neurosensory Testing, and published within the past 15 years., Results: Across 10 studies conducted between 2011 and 2023, analysis was performed on 149 patients and 151 reconstructed nerves. Allogeneic nerve grafts showed an average FSR rate of 88.0%. Kaplan-Meier analysis of time to FSR postoperatively revealed that of those achieving FSR, 80% achieved it within 6 months and 98% achieved it by 1 year. The mean graft length was 29.92 mm ± 17.94 mm. The most common etiology for nerve damage was third molar extractions (23.3%). Sex distribution among patients revealed that 85 were female (57.0%) and 64 were male (43.0%)., Conclusion: Our primary hypothesis was supported as nerve allografts achieved high rates of FSR. FSR was achieved in normative timeframes, which is 6 to 12 months postoperatively. Furthermore, allografts reduced the risk of posttraumatic trigeminal neuropathy. Time from injury to repair, graft length, etiology of nerve damage, and sex did not affect FSR. As the assessed variables in our study did not affect outcomes, there needs to be a more nuanced approach to understanding and addressing various factors influencing sensory recovery., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ablative mandibular resection with sacrifice of the inferior alveolar nerve (IAN) results in loss of sensation and decreased quality of life., Purpose: The purpose of this study is to evaluate functional sensory recovery (FSR) of immediate IAN allograft reconstruction performed during ablative mandibular resection at 1 year following surgery., Study Design, Setting, Sample: This is a single-center retrospective cohort study that included consecutive subjects who underwent mandibular resection with IAN discontinuity and used a nerve allograft of ≥40 mm., Predictor/exposure/independent Variable: The primary predictor variable is the use of an immediate nerve allograft in mandibular reconstruction., Main Outcome Variable(s): The main outcome variable is FSR at 1 year using the Medical Research Council Scale., Covariates: Covariates include subject age, sex, specific pathology, nerve gap length, and development of neuropathic pain., Analyses: Statistical analysis of comparison of neurosensory outcomes was measured by bivariate statistics, weighted values, repeated measures, analysis of variance, and McNemar test., Results: The study sample was composed of 164 subjects, of whom 55 (33.5%) underwent nerve allograft reconstruction and 30 (18.3%) did not have nerve reconstruction. Seventy-nine subjects (48.2%) did not meet the inclusion criteria. In the entire nerve allograft group of 55 subjects, FSR was achieved in 80% at 1 year; however, in benign disease alone, 31 of 33 (94%) achieved FSR at 1 year. In the nonallograft group (all benign disease), only 2 of 30 (7%) achieved FSR at 1 year. The significant covariates were age and pathology. Benign pathologic resections were 5.2 times more likely to achieve FSR than malignancies, and all subjects ≤ 18 years of age achieved FSR. After adjusting for age, sex, pathology, nerve gap length, nerve allograft was significantly associated with achieving FSR at 1 year (adjusted odds ratio = 5.52, 95% confidence interval = (1.03, 29.51), P value = .045 < .05)., Conclusion and Relevance: Immediate long-span IAN allograft reconstruction is effective in restoration of sensation with an overall 80% of subjects achieving FSR at 1 year, while benign disease resulted in 94% FSR at 1 year. Immediate IAN reconstruction should be considered with mandibular resection involving the IAN, especially for children and benign disease., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

This technical note describes an innovation that addresses a clinical problem in inferior alveolar nerve (IAN) reconstruction. In some cases of mandibular resection, there is a need to resect a significant amount of the IAN along with the pathologic lesion and this may result in a lack of a distal nerve stump for completion of the neural anastomosis. This technical note offers the option to perform the distal neurorrhaphy into the residual soft tissues with the expectation that axonal sprouting will occur and result in lower lip and chin sensory reinnervation. There are no inherent risks or additional costs. The significance of this technique is that it permits IAN reconstruction in cases where the actual nerve stump is not available and improves patient care. There should be no challenges or delays to implementing this innovation for surgeons who reconstruct the IAN during ablative mandibular resection., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Tensionless adaptation of nerve ends is a challenging task in the repair of damaged inferior alveolar nerve (IAN). A new technique is introduced with posterior ostectomy of a mandibular distal segment after sagittal splitting for nerve bundle traction to tensionless anastomosis of nerve ends. We were able to create tensionless anastomosis of an IAN defect without autogenous or alloplastic graft using this method. This method is suitable for neurorrhaphy after neuroma removal in cases of IAN damage during dental procedures., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Post operative nerve injury following mandibular third molar (M3M) potentially impacts a significant number of patients. A lack of consensus for the management of trigeminal nerve injuries exists. It is important to know how clinicians manage these injuries, and how confidently. A 16-question online survey using SurveyMonkey was developed and sent to all current UK members of three oral srelated societies (ABAOMS, BAOS and BAOMS) from January 2021 to March 2021. The survey consisted of open free text, binomial and variable scale responses related to the management of inferior alveolar nerve and lingual nerve injuries. A total of 158 clinicians responded to the survey. The average number of M3M removed monthly over the last three years by a clinician was 25. The average number of nerve injuries seen in a clinician's practice, within the last three years, was three. Over two-thirds of respondents were only somewhat confident, not so confident, or not at all confident in the management of patients with inferior alveolar nerve (IAN) and lingual nerve (LN) injury. In occurrence of an injury, only 45% stated they would make an onward referral and a minority of clinicians had access to surgical repair within their own unit. Free text responses highlighted themes of a lack of UK awareness of management interventions and pathways for these patients. Clear national guidance on managing trigeminal nerve injuries was a commonly desired theme from responding clinicians. Joint speciality partnerships and a national nerve repair registry is now required., (Copyright © 2022 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To report 12 patients with neurotrophic keratopathy due to the trigeminal nerve injury after intracranial tumor surgeries underwent minimally invasive corneal neurotization and evaluate the outcomes of corneal reinnervation., Methods: Twelve patients (12 eyes) with neurotrophic keratopathy caused by the trigeminal nerve injury after intracranial surgeries received minimally invasive corneal neurotization. All the preoperative central corneal sensation was under 5 mm, and minimally invasive corneal neurotization was performed over 6 months after the intracranial surgery. Follow-up was conducted 1 week and 1 month after the surgery and then every 3 months. Twelve healthy age-matched participants were enrolled as controls. The indicators included corneal sensation, best-corrected visual acuity, corneal nerve fiber length and branch density, diameter of nerve trunk, corneal ulcer lesion ratio, and sensation of the contralateral forehead., Results: Mean follow-up was 24.7 ± 7.1 months. Mean central corneal sensation rose from 0.4 ± 1.4 to 31.7 ± 21.8 mm. Corneal nerve fiber length improved from 9.56 ± 5.00 to 14.96 ± 4.65 mm/mm 2 and corneal nerve branch density and diameter of nerve trunk both increased ( p  < .01 and p  < .05, respectively). Corneal lesion ratio decreased from 0.17 ± 0.12 to 0.10 ± 0.10 ( p  < .01)., Conclusions: Minimally invasive corneal neurotization promotes corneal reinnervation for patients with neurotrophic keratopathy induced by the trigeminal nerve injury after intracranial surgeries. The process of corneal reinnervation after minimally invasive corneal neurotization often lasts over 12 months, and it takes about 18 months to return to a higher level. Corneal sensation and corneal nerve fiber length are related to clinical outcomes such as corneal ulcer lesion and best-corrected visual acuity. The effect on the sensation of the contralateral side forehead is temporary, and most patients can restore normal forehead sensation of the contralateral side.

Background: The lag time between injury and treatment (LTIT) plays an important role in reduction of complications in mandibular fractures. The aim of this study was to measure the effect of LTIT on recovery of the inferior alveolar nerve (IAN) neurosensory disturbances (NSDs) following surgical management of mandibular body fractures., Methods: This was a prospective cohort study. Patients who had a unilateral mandibular body fracture with paresthesia were studied. Paresthesia was evaluated by 2-point discrimination (TPD) test, brush stroke test and self-reporting before and 6 months after the surgical procedure., Results: Forty-five patients were studied. There was a correlation between LTIT and TPD test result and self-reported paresthesia at 6 months, postoperatively (P = 0.001). Fifteen patients (33.3%) had complete improvement in NSD 6 months after treatments (group 1) and 30 patients (group 2) had hyposthesia (N = 17, 37.77%) and paresthesia (N = 13, 28.88%). There was a significant difference in LTIT between groups 1 and 2 at 6 months postoperatively (P = 0.001). Cox regression model demonstrated the hazard ratio increased significantly for self-reported NSD when treatment was done 10 days after trauma (P = 0.001, confidence level = 95%)., Conclusion: It seems that conduction of open reduction with internal rigid fixation shortly after mandibular fracture may shorten the recovery time of NSDs of the IAN following mandibular body fractures.

Trigeminal injury can cause intractable facial pain. However, surgical approaches to the superior alveolar nerves have not been widely described. We report resection of the anterior superior alveolar nerve (ASAN), middle superior alveolar nerve (MSAN), and posterior superior alveolar nerve (PSAN) in a patient with refractory facial pain and outline an algorithmic approach to the treatment of trigeminal nerve injury. A 56-year-old woman presented with a 3-year history of refractory facial pain in the distribution of the right superior alveolar nerves after dental trauma. As a comorbidity, central sensitization developed in the patient, manifesting in the uninjured oral areas being painful. After several temporary nerve blocks and medical management, the patient underwent resection of the ASAN, MSAN, and PSAN, as well as neurolysis of the infraorbital nerve, through a Caldwell-Luc approach. One week postoperatively, she reported substantial improvement in pain symptoms, including burning and temperature sensitivity, in the right maxilla. These findings were maintained at 7 months, without any maxillary sinus complications. Central sensitization caused continued intraoral symptoms. The ASAN, MSAN, and PSAN can be surgically resected within the maxillary sinus to treat refractory neuropathic pain. An etiology-based approach can guide successful treatment of trigeminal neuropathy. Central sensitization as a comorbidity must be addressed medically., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Compared with cone beam computed tomography (CBCT), magnetic resonance imaging (MRI) might be superior for the diagnosis of nerve lesions associated with implant placement., Study Design: A patient presented with unilateral pain associated with dysesthesia in the region of the right lower lip and chin after implant placement. Conventional orthopantomography could not identify an association between the position of the inferior alveolar nerve and the implant. For 3-dimensional display of the implant in relation to the surrounding anatomy, CBCT was compared with MRI., Results: MRI enabled the precise depiction of the implant position and its spatial relation to the inferior alveolar nerve, whereas the nerve position and its exact course within the mandible could not be directly displayed in CBCT., Conclusion: MRI may be a valuable, radiation-free diagnostic tool for the visualization of intraoral hard and soft tissues, offering an objective assessment of nerve injuries by a direct visualization of the inferior alveolar neurovascular bundle., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The authors report the case of a 43-year-old woman who underwent endodontic treatment of the right second mandibular molar with substantial extrusion of endodontic material into the mandibular canal. The patient presented at the Department of Oral and Maxillofacial Surgery with a persistent total anaesthesia of the lower lip and chin after two months. 2D panoramic view and 3D CT-scan examination highlighted the overfilling into the mandibular canal with a more than 50% stenosis of the canal and a consequently significant compression of the dental pedicle. A surgical decompression of the inferior alveolar nerve was performed through an inferior vestibular approach, using PiezoSurgery ® . The tooth was conserved. After a period of 8days, paraesthesia of the lower lip and chin appeared. Thermoalgic sensitivity was recovered at 1month. At 3months postoperatively, the patient had recovered protopathic and epicritic sensitivity. Dental prosthetic rehabilitation was finally achieved one year postoperatively. The authors discuss the physiopathology of nervous injuries during dental procedures, and further strategies in the case of persistent neurologic disorders., (Copyright © 2017. Published by Elsevier Masson SAS.)

Purpose: Injuries of the inferior alveolar nerve (IAN) related to endodontic treatment are being increasingly reported. However, consensus on the preferred intervention and the timing of and indications for surgical treatment is lacking. Here, we describe our experience with painful IAN injuries arising from endodontic treatment and requiring prompt microsurgical treatment., Methods: Seven consecutive patients with painful IAN injuries were referred to the Maxillofacial Surgery Unit of San Paolo Hospital in Milan. All patients had undergone root canals endodontic treatment in the mandibular molar or premolar between 2007 and 2014. The time elapsed between injury and referral for surgical treatment ranged from 10 days to 20 months. Each patient was treated by one of several different microsurgical procedures, described herein., Results: Overall, neurosensory status and IAN-related pain improved in all seven patients. The best results were obtained by IAN replacement with a sural nerve graft. However, complete sensory recovery was not achieved in any of the patients., Conclusions: Although our sample includes only seven patients, early surgical treatment with an interpositional sural nerve graft seems to allow neurosensory recovery. Less satisfactory results are achieved in patients with IAN injuries of > 12 months duration.

Purpose: During trigeminal nerve repair, a gap is sometimes encountered that prevents the tension-free apposition of nerve endings. The use of a processed acellular nerve allograft is a novel technique that shows promise in overcoming this problem. The goal of the present study was to support the slowly evolving body of evidence that acellular processed nerve allografts (Avance; Axogen, Alachua, FL) are a viable alternative to autogenous nerve grafting and the use of conduits for reconstructing defects of the trigeminal nerve., Patients and Methods: The study design consisted of a retrospective review of the medical records of patients referred to Rutgers School of Dental Medicine for management of trigeminal nerve injuries from July 2008 to August 2014. Sixteen patients met the inclusion criteria for the present study. All patients underwent nerve grafting using a processed nerve allograft. All operations were performed by the same surgeon (V.Z.). Serial neurosensory testing was performed by 1 clinician (V.Z.) in a standardized fashion. The primary outcome variable was the interval to functional sensory recovery as defined by the Medical Research Council Scale., Results: The participants ranged in age from 16 to 62 years (mean 32). Of the 16 patients, 12 were female (75%) and 4 were male (25%), and 3 were smokers (18.75%) and 13 were nonsmokers (81.25%). One half of the patients (n = 8; 50%) underwent surgery on the inferior alveolar nerve, and 8 (50%) underwent surgery on the lingual nerve. The most common mechanism of injury was impacted third molar removal (n = 9; 56.25%) Of the 16 patients, 15 (93.75%) achieved functional sensory recovery during the study period., Conclusions: The results of the present study support the hypothesis that processed nerve allografts are effective in reconstructing small (<2-cm) trigeminal nerve defects., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Iatrogenic injury in oral surgery is the most frequent cause of sensory disturbance in the distribution of the inferior alveolar nerve (IAN) and mental nerve.Inferior alveolar nerve damage can occur during third molar extraction, implant location, orthognathic surgery, preprosthetic surgery, salivary gland surgery, local anesthetic injections or during the resection of benign or malignant tumors.Injuries to the IAN can be caused also by endodontic treatment of mandibular molars and premolars when filling material is forced into the tooth and mandibular canal.The sensory disturbances that could follow a damage of the IAN could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and sometimes a painful anesthesia that strike ipsilateral lower lip, chin, and teeth. These can undermine life quality by affecting speech, chewing, and social interaction.Treatment of these complications is sometimes difficult and could consist in observation or in surgical decompression of the involved nerve to relieve the patient's symptoms and improve sensory recovery. The most debated points are the timing of intervention and the effective role of decompression in clinical outcome-improvement.The purpose of this article is to show authors' experience with 2 patients treated with microsurgical nerve decompression to remove endodontic material from the mandibular canal and providing also a comprehensive review of the literature.

A 60-year-old woman presented with several years increasing right upper eyelid ptosis. She had undergone surgical decompression of the right trigeminal nerve in the posterior cranial fossa 15 years earlier for trigeminal neuralgia. This left her with permanent numbness in the second and third divisions of the trigeminal nerve. In addition to the ptosis, she was found to have right enophthalmos and a smaller right face. CT scans showed a smaller midfacial skeleton on the right and a depressed orbital floor. The changes were different to those seen in silent sinus syndrome. Photographs taken over many years showed the facial changes were acquired and came on gradually many years after the trigeminal nerve injury. It is possible that trigeminal nerve injury may lead to trophic changes in the facial skeleton, but these have not been previously reported.

Purpose: The aim of this study was to investigate the prevalence and length of the anterior loop (AL), the distance from this landmark to the alveolar crest and its relation with the shape of the foramen and emergency pattern in the Spanish population on helical computed tomography scan (helical CT scan) through tridimensional reconstructions., Methods: Helical CT scan images of 41 patients aged 65 or older were analyzed. A total of 82 human hemi-mandibles were examined in this study. A tridimensional reconstruction of each mandible and Inferior Alveolar Nerve canal was created in AMIRA ® software (AMIRA, Mercury Computer Systems, Berlin, Germany). Prevalence, length and distance between the AL, mental foramen and alveolar ridge were measured. This retrospective observational study was performed according to the STROBE guidelines., Results: Prevalence of the AL was 53.7 % (n = 44) and the mean length was 1.3 ± 0.64 mm. The mean distance from the highest point of the loop to the alveolar ridge was 13.4 ± 2.8 mm. The mean diameter of the mental foramen was 3.5 ± 0.65 mm and the proportion of the oval-shaped was 62.2 % (n = 51) and round-shaped was 37.8 % (n = 31). The study found that patients with type 1 pattern emergency pattern had a higher prevalence of the AL (p = 0.03)., Conclusions: Prevalence, location and length of the anterior loop can be overlooked if only two-dimensional pre-surgical studies are performed. Therefore, three-dimensional imaging and modeling of anatomic structures should be used for the pre-operative examination of the interforaminal area. Given the wide variability of the emergency pattern of the mental nerve and the prevalence and location of the anterior loop, it should be studied in every patient individually.

Purpose: Contemporary management of ablative jaw defects includes not only hard and soft tissue reconstruction, but also restoration of neurosensory function. The goal of this study was to determine the outcomes of immediate reconstruction of long-span defects (≥50 mm) of the inferior alveolar nerve (IAN) after ablative mandibular resection using allogeneic nerve grafts., Materials and Methods: A retrospective cohort study of patients who underwent immediate reconstruction of IAN gaps of at least 50 mm with allogeneic nerve graft (AxoGen Avance, Alachua, FL) at a single academic medical center by a single surgeon (M.M.) from September 2013 to March 2015 was completed. Demographic and clinical data were collected for each patient and analyzed using clinical neurosensory testing and were reported using the Medical Research Council Scale (MRCS) for functional sensory recovery. In addition, patient subjective perception of neurosensory recovery was recorded using a visual analog scale (VAS). Subjective (VAS) and objective (MRCS) measurements of functional sensory recovery were recorded and compared across the study population. In addition, examined demographic and clinical data included patient age, gender, pathology, length of nerve allograft, and follow-up period., Results: Of 12 with nerve repairs, 7 patients met the inclusion criteria. The average age was 34.7 years (range, 18 to 61 yr) and 71.4% were men. All IAN defects resulted from resection of mandibular pathology (6 benign lesions, 1 malignant lesion). Six of the 7 IAN defects were reconstructed with a 70-mm nerve allograft, and 1 nerve defect was reconstructed with a 50-mm graft. Mean follow-up time was 17.7 months (range, 10 to 27.5 months). Mean VAS score reported was 3.7 (range, 0 to 7). In addition, 85.7% of patients displayed return of some superficial pain and tactile sensation without over-response (S3), with 14.3% displaying good stimulation localization (S3+). The patient who displayed S3+ recovery underwent reconstruction with the 50-mm graft. Only 1 of the 7 patients had no neurosensory recovery (S0)., Conclusions: Immediate reconstruction of the IAN with allogeneic nerve grafting of long-span defects (≥5 cm) is a viable and predictable option to achieve useful functional sensory recovery., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: To evaluate the neurosensory outcome of management of damaged inferior alveolar nerves caused by endodontic overfilling and to assess the efficacy of delayed surgical intervention., Methodology: Nine patients who underwent surgical removal of extruded endodontic material were included. All patients were evaluated for neurosensory function using a set of standardized tests. The outcome of surgical intervention was evaluated through patient interview and quantitative statistical analysis., Results: Surgical procedures included foreign body removal, microsurgical external/internal decompression, excision of neuroma followed by nerve repair, and excision of damaged nerve segment with interpositional nerve graft. Seven of the nine patients had significant improvement according to the follow-up neurosensory assessment. Four patients reported significant improvement, three patients reported mild improvement and two patients reported no appreciable improvement in the Visual Analog Scale (VAS). Two patients who reported no appreciable improvement in VAS also did not achieve FSR. In these patients, calcium hydroxide was spread widely along the IAN and a surgical approach was obtained via sagittal spit osteotomy. The mean time to reach FSR was 222.7 (±41.8) days with a range of 106-397 days. In the early repair group who received surgery within 60 days, three out of five patients achieved FSR in a mean time of 198.0 (±76.2) days. The mean time to FSR in all four subjects who received surgical attention over 60 days after injury was 241.3 (±139.8) days with a range of 106-397 days. As all four cases in the late repair group with limited amount of nerve injury achieved FSR, only 3 of 5 early repair cases with wide-spread injury achieved a similar outcome., Conclusion: The results of this case series confirmed the notion that surgical management of the inferior alveolar nerve is effective in the treatment of nerve injuries caused by endodontic extrusion of calcium hydroxide paste. Delayed surgical repair of the inferior alveolar nerve can be indicated and helpful for the neurosensory recovery of damaged IAN, however, the surgical management was less effective in case of widespread nerve injuries., (© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Objective: To prospectively evaluate the longitudinal subjective and objective outcomes of the microsurgical treatment of lingual nerve (LN) and inferior alveolar nerve (IAN) injury after third molar surgery., Materials and Methods: A 1-year longitudinal observational study was conducted on patients who received LN or IAN repair after third molar surgery-induced nerve injury. Subjective assessments ("numbness", "hyperaesthesia", "pain", "taste disturbance", "speech" and "social life impact") and objective assessments (light touch threshold, two-point discrimination, pain threshold, and taste discrimination) were recorded., Results: 12 patients (10 females) with 10 LN and 2 IAN repairs were recruited. The subjective outcomes at post-operative 12 months for LN and IAN repair were improved. "Pain" and "hyperaesthesia" were most drastically improved. Light touch threshold improved from 44.7 g to 1.2 g for LN repair and 2 g to 0.5 g for IAN repair., Conclusion: Microsurgical treatment of moderate to severe LN injury after lower third molar surgery offered significant subjective and objective sensory improvements. 100% FSR was achieved at post-operative 6 months.

Background: Several deep brain stimulation (DBS) targets have been explored for the alleviation of trigeminal anaesthesia dolorosa. We aimed to characterise the analgesia produced from the periaqueductal grey (PAG) and centromedian-parafascicular (CmPf) nucleus using a within-subject design., Method: We report a case series of 3 subjects implanted with PAG and CmPf DBS systems for the treatment of anaesthesia dolorosa. At follow-up, testing of onset and offset times, magnitude, and thermal and mechanical sensitivity was performed., Results: The mean pain score of the cohort was acutely reduced by 56% (p < 0.05) with PAG and 67% (p < 0.01) with CmPf stimulation at mean time intervals of 38 and 16 min, respectively. The onset time was 12.5 min (p < 0.05) for PAG stimulation and 2.5 min (p < 0.01) for CmPf. The offset time was 2.5 min (p < 0.05) for PAG and 12.5 min (p < 0.01) for CmPf. The two targets were effective at different stimulation frequencies and were not antagonistic in effect., Conclusion: The mechanisms by which stimulation at these two targets produces analgesia are likely to be different. Certain pain qualities may respond more favourably to specific targets. Knowledge of onset and offset times for the targets can guide optimisation of stimulation settings. The use of more than one stimulation target may be beneficial and should be considered in anaesthesia dolorosa patients., (© 2016 The Author(s) Published by S. Karger AG, Basel.)

Objective: Functional sensory recovery from microsurgical intervention for inferior alveolar nerve (IAN) injuries resulting from endodontic treatment were evaluated using a retrospective chart review. Other variables assessed included time from injury to surgery as well as other factors which improved functional neurosensory recovery (FSR)., Method and Materials: This case series of seven patients evaluated the outcome of IAN microsurgery following endodontic-related nerve injuries. All patients were referred, evaluated, and operated on by the primary investigator (VBZ). Surgical intervention consisted of external and/or internal neurolysis with irrigation of the mandibular canal and decompression of the affected IAN as well as allogeneic nerve graft in one patient. Preoperative and postoperative sensory levels were recorded and FSR was assessed using the Medical Research Council scale., Results: Seven subjects with a mean age of 35.57 years (range 22 to 55 years old) opted to undergo trigeminal nerve microsurgery for management of their IAN injury resulting from endodontic treatment of mandibular molar teeth. Six women and one man were included in this population. The majority of subjects presented with an initial chief complaint of dysesthesia and hypoesthesia. The mean interval between nerve injury and surgical treatment was 15 weeks (range 1 to 40 weeks). All patients had preoperative sensory level of S0, S1, or S2+, and achieved FSR following surgery. Two patients had postoperative sensory level of S3, four patients had a postoperative sensory level of S3+, and one had a postoperative sensory level of S4 (complete recovery)., Conclusions: The results of this study suggest that trigeminal nerve microsurgery for the surgical treatment of endodontic injuries to the IAN can improve neurosensory function. Surgical intervention in this study was beneficial to alleviate neurosensory deficits and symptoms for those injuries to the IAN caused by endodontic treatment.

Aim: The aim of this study was the clinical and radiological evaluation in severe mandibular atrophy (class V-VI Cadwood-Howell) of bone grafts with homologous fresh frozen bone (FFB) in patients with dysesthesia of the inferior alveolar nerve with or without transposition of the NAI in order to perform a proper implant-prosthetic rehabilitation., Methods: This article presents our experience in mandibular reconstructions performed in 12 patients with severe mandibular atrophy and dysesthesia performing onlay grafts with FFB and subsequent implant-prosthetic rehabilitation., Results: The surgical protocol of homologous bone graft in symptomatic patients with severe mandibular atrophy presented an excellent clinical outcome with disappearance of dysesthesia in all patients treated, good graft integration and a complete implant-prosthetic rehabilitation with loss of only 3 implants at the 24-36 month follow up visit., Conclusion: Homologous bone grafting in patients with severe mandibular atrophy may be a viable therapeutic option in cases of prosthetic reconstruction in those symptomatic patients who cannot tolerate removable dentures, reducing intraoperative time, patient morbidity and the complications in common sites of autologous bone graft removal.

Background: Posttraumatic midface pain secondary to injury of the anterior superior alveolar nerve (ASAN) is characterized as pain localized to the central and lateral incisors, canines, and maxilla. This nerve is susceptible to injury and subsequent formation of neuromas after midface trauma. Surgical intervention requires an accurate and precise understanding of the course of the ASAN., Methods: Dissections of 12 human cadaver heads were conducted to identify the course of the ASAN through the canalis sinuosus (CS). Fifty 1-mm slice face computed tomographic scans were evaluated to document the dimensions and course of the CS., Results: The ASAN branched laterally from the infraorbital nerve before reaching the infraorbital rim in all cadavers. The bifurcation occurred 18 mm posterior to the infraorbital rim (range, 10-30 mm). At a point 25 mm inferior to the infraorbital rim, the ASAN is found 3.4 mm lateral to the piriform aperture (range, 3-4 mm). Radiographic analysis demonstrated a 12.9-mm horizontal length of the CS across the anterior maxilla (SD, 2.2 mm), a distance of 4.8 mm between the piriform aperture and the CS (SD, 1.2 mm), and 11.7 mm vertical length of the CS along the piriform aperture (SD, 3.0 mm)., Conclusions: The ASAN maintains consistent coordinates at specific points along its course through the midface. An improved understanding of the course of the ASAN will guide future diagnosis of injury to this nerve and surgical intervention for patients with posttraumatic midface pain secondary to ASAN injury.

Nerve-related complications are being reported with increasing frequency following oral and dental surgery, and typically involve the inferior alveolar nerve (IAN). We assess herein the etiology of neuropathic pain related to IAN injuries, and describe the various surgical treatment techniques available. Between 2007 and 2013, 19 patients were referred to the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) with pain in the area supplied by the IAN, which developed following endodontic treatment, oral surgery and maxillofacial surgery. All patients underwent IAN surgery by several different microsurgical procedures. Most of the patients affected by pain before surgery experienced complete or partial amelioration of symptoms. All patients receiving sural nerve grafts were pain-free 12 months after surgery. In five patients the operation was unsuccessful. In 78.94% of cases, a significant increase in nerve function was observed. Pain following IAN surgical damage may be addressed by microsurgery; nerve substitution with a sural nerve interpositional graft appears to represent the most efficacious procedure. Scar releasing, nerve decompression and nerve substitution using vein grafts are less effective. Removal of endodontic material extravasated into the mandibular canal is mandatory and effective in patients experiencing severe pain. Surgery should be performed within 12 months postoperatively, ideally during the first few weeks after symptoms onset., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The inferior alveolar nerve (IAN) and lingual (LN) are susceptible to iatrogenic surgical damage. Systematically review recent clinical evidence regarding IAN/LN repair methods and to develop updated guidelines for managing injury. Recent publications on IAN/LN microsurgical repair from Medline, Embase and Cochrane Library databases were screened by title/abstract. Main texts were appraised for exclusion criteria: no treatment performed or results provided, poor/lacking procedural description, cohort <3 patients. Of 366 retrieved papers, 27 were suitable for final analysis. Treatment type for injured IANs/LNs depended on injury type, injury timing, neurosensory disturbances and intra-operative findings. Best functional nerve recovery occurred after direct apposition and suturing if nerve ending gaps were <10 mm; larger gaps required nerve grafting (sural/greater auricular nerve). Timing of microneurosurgical repair after injury remains debated. Most authors recommend surgery when neurosensory deficit shows no improvement 90 days post-diagnosis. Nerve transection diagnosed intra-operatively should be repaired in situ; minor nerve injury repair can be delayed. No consensus exists regarding optimal methods and timing for IAN/LN repair. We suggest a schematic guideline for treating IAN/LN injury, based on the most current evidence. We acknowledge that additional RCTs are required to provide definitive confirmation of optimal treatment approaches., (© 2015 John Wiley & Sons Ltd.)

The damage of inferior alveolar nerve causes some functional problem including numbness of lower lip and drooling. During segmental mandibulectomy, inferior alveolar nerve commonly resected, therefore, it is ideal to reconstruct the nerve to get better functional result. Sensory recovery was assessed after mandibular reconstruction using free fibula osteoseptocutaneous flap in thirteen cases. In six cases, the mental nerve reconstruction was performed simultaneously, and in seven cases, the mental nerve reconstruction was not performed. In the case that the mental nerve was reconstructed simultaneously, unilateral mental nerve reconstruction was performed in five cases, and bilateral mental nerve reconstruction was performed in one cases. More than one year after the reconstruction, sensory recovery was assessed and compared between the group that the mental nerve was reconstructed and the group that was not reconstructed. Our results showed almost a normal sensory recovery of the lips on the reconstructed side more than one year after the reconstruction in reconstructed group. In contrast, sensory recovery was poor in non-reconstructed group and non-reconstructed side. These results showed that mental nerve reconstruction at the same time as mandibular reconstruction affects the postoperative mandibular function. The sural nerve can be harvested from the same donor site of the free fibula osteoseptocutaneous flap and such mental nerve reconstruction with nerve grafting can be completed within an hour. Most cases of mandibular reconstruction using a free fibula osteoseptocutaneous flap transfer can therefore be candidates for mental nerve reconstruction at the time of mandibular reconstruction., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: Although treating facial palsy is considered debilitating for patients, trigeminal nerve palsy and sensory deficits of the face are overlooked components of disability. Complete anesthesia leaves patients susceptible to occult injury, and facial sensation is an important component of interaction and activities of daily living. Sensory reconstruction is well established in the restoration of hand sensation; however, only one previous report proposed a surgical strategy for sensory nerve reconstruction of the face with use of nerve transfers. Nerve transfers, when used alone, have limited application because of their restricted arc of rotation in the face; extending their arc by adding nerve grafts greatly expands their utility. The following cases demonstrate the early results after V2 and V3 reconstruction with cross-face nerve grafts in three patients with acquired trigeminal nerve palsy. Cross-face nerve grafts using the sural nerve permit more proximal reconstruction of the infraorbital and mental nerves, which allows reinnervation of their entire cutaneous distribution. All patients demonstrated improved sensation in the reconstructed dermatomes, and no patients reported donor-site abnormalities. Cross-face nerve grafts result in minimal donor-site morbidity and are promising as a surgical strategy to address sensory deficits of the face., Clinical Question/level of Evidence: Therapeutic, V.

Purpose: The present study describes the results of using a processed nerve allograft, Avance Nerve Graft, as an extracellular matrix scaffold for the reconstruction of lingual nerve (LN) and inferior alveolar nerve (IAN) discontinuities., Patients and Methods: A retrospective analysis of the neurosensory outcomes for 26 subjects with 28 LN and IAN discontinuities reconstructed with a processed nerve allograft was conducted to determine the treatment effectiveness and safety. Sensory assessments were conducted preoperatively and 3, 6, and 12 months after surgical reconstruction. The outcomes population, those with at least 6 months of postoperative follow-up, included 21 subjects with 23 nerve defects. The neurosensory assessments included brush stroke directional sensation, static 2-point discrimination, contact detection, pressure pain threshold, and pressure pain tolerance. Using the clinical neurosensory testing scale, sensory impairment scores were assigned preoperatively and at each follow-up appointment. Improvement was defined as a score of normal, mild, or moderate., Results: The neurosensory outcomes from LNs and IANs that had been microsurgically repaired with a processed nerve allograft were promising. Of those with nerve discontinuities treated, 87% had improved neurosensory scores with no reported adverse experiences. Similar levels of improvement, 87% for the LNs and 88% for the IANs, were achieved for both nerve types. Also, 100% sensory improvement was achieved in injuries repaired within 90 days of the injury compared with 77% sensory improvement in injuries repaired after 90 days., Conclusions: These results suggest that processed nerve allografts are an acceptable treatment option for reconstructing trigeminal nerve discontinuities. Additional studies will focus on reviewing the outcomes of additional cases., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bone morphogenetic protein 2 (BMP-2) has been used to reconstruct mandibular defects. An elegant addition to this reconstruction method would be incorporation of a nerve graft wrapped in a BMP-2 carrier to reconstitute the inferior alveolar nerve (IAN) and restore sensation to the lower face. We developed a rabbit model to determine the effect BMP-2 has on nerve regeneration following neurorrhaphy., Methods: An inferior border mandibulectomy was created in 16 adult New Zealand white rabbits. The IAN was protected, divided, and repaired with either primary neurorrhaphy or reverse autografts. Bone defects were treated with no treatment controls (n = 2), absorbable collagen sponge (ACS) (vehicle controls) (n = 7), and ACS soaked in BMP-2 (treatment group) (n = 7). Animals underwent computed tomography (CT) 2 days and 6 weeks postoperatively. The percent bone defect healing was calculated using Amira 3D imaging software. At 6 weeks, IANs were harvested mesial to the reconstruction and were evaluated with toluidine blue histology to identify myelinated axons. Reconstructed mandible segments were evaluated with micro-CT and hematoxylin-eosin histology., Results: Bone morphogenetic protein 2-treated animals demonstrated significantly more bone healing than did the ACS and empty defect groups (82%, 38%, 44%, respectively; P < 0.01). One hundred percent of ACS-treated nerves (n = 4) demonstrated axon regrowth, whereas only 25% of BMP-2-treated nerves (n = 4) did. Micro-CT and histology showed BMP-2 caused bone growth around the IAN, but regenerated bone infiltrated the repair site and created a physical barrier to axon growth., Conclusions: Bone morphogenetic protein 2 can successfully heal bone defects in the rabbit mandible, but ectopic bone growth can inhibit IAN recovery after repair. Level of Evidence: Not gradable.

Endodontic overfilling involving the mandibular canal may cause an injury of the inferior alveolar nerve (IAN). We report a case of disabling dysesthesia and paresthesia of a 70-year-old man after endodontic treatment of his mandibular left third molar that caused leakage of root canal filling material into the mandibular canal. After radiographic evaluation, extraction of the third molar and distal osteotomy, a surgical exploration was performed and followed by removal of the material and decompression of the IAN. The patient reported an improvement in sensation and immediate disappearance of dysesthesia already from the first postoperative day.

Introduction: Bifocal fractures of the mandible often associate the angle and condyle or symphysis. Little data is available on biangular fractures. The authors had for aim to study their characteristics and to suggest an adapted management., Material and Methods: We retrospectively reviewed the records of patients operated on for a biangular fracture from January 2005 to December 2009. The impact of a third molar was evaluated using Pell and Gregory's and Shiller's classifications., Results: Six hundred and forty patients underwent surgery for a mandibular fracture, seven of whom (1.1%) for biangular fractures. The patients' mean age was 27.6 years. Patients were predominantly men (85.7%). Assaults or brawls were the most frequent etiology (85.7%). The mechanism was direct impact in every case. The inferior alveolar nerve was injured in 57.1% of cases. There was an impacted third molar in 71.4% of cases. Most of the time, a single miniplate was sufficient for each angle. Two cases of postoperative infection were noted. The mean follow-up was 52.2months. The occlusion was restored in every case. Three patients presented with neurological sequels in the V3 area., Discussion: Biangular fractures are rare and present a high risk of infection and neurological sequels. The presence of a mesioangular impacted third molar seems to be a predisposing factor. The risk of neurological sequels requires performing surgery rapidly., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: Surgical exploration and end-to-end neurorrhaphy is the preferred management for traumatic facial nerve injury. Traditionally, finding the cut ends of facial nerves depends mainly on a surgeon's experience. In this study, a nerve monitoring system to help the surgeon quickly and accurately identify, confirm, and locate the cut ends of facial nerve branches was investigated., Patients and Methods: Six patients with traumatic facial nerve injury were selected, and the nerve monitoring system was applied during the surgical process of facial nerve exploration and anastomosis. Operation time and surgical outcome were used to evaluate the effect of this method., Results: The surgical procedures required 6 to 15 minutes (mean, 10 minutes) for detecting and dissecting each cut end of a facial nerve branch. All cut ends of injured facial nerve branches were found during surgery in all 6 patients, and no intraoperative complications were encountered. The postoperative function of the facial nerve, evaluated by clinical examination and diagnostic electroneurography, was satisfactory and symmetrical in all 6 patients at 3 months., Conclusion: Using a nerve monitoring system could effectively help surgeons achieve rapid and accurate identification of the cut ends of facial nerves during surgical facial nerve exploration for traumatic facial nerve injury., (Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Trigeminal nerve injury is a rare, but serious complication of a common procedure, which results in a clinically relevant problem that deserves attention. The emergence of microsurgical repair of trigeminal injury has provided clinicians with treatment options for patients who experience persistent neurosensory deficits. The area of microsurgical repair of trigeminal nerves is now in its adolescence. While great strides have been made in the field since its conception, it is certain that a new generation of oral and maxillofacial surgeons wil bring further progress to the field. In the future, better quantitative sensory testing methods, more accurate imaging modalities, and advances in surgical technique will certainly improve the management of patients with impacted third molars. As clinicians, every day we are confronted with the management of impacted third molars. It is important to evaluate each patient individually with an appropriate clinical and radiographic exam. Every patient should be informed of the relative risks and benefits of third molar removal and a joint decision should be reached between the clinician and patient regarding ideal treatment. However, even with ideal management, complications will occur. If a patient does present with signs of a nerve injury the clinician should carefully document the neurosensory deficit and monitor the patient over time. If the patient exhibits a significant sensory deficit for more than one month a referral for evaluation to a tertiary care center capable of surgical repair of the injury is recommended. The occurrence of a "trigger" or Tinel's like sign is improtant as an indication for surgery but may not occur for a month after injury.

Head and neck tumor surgery or traumatic injuries in the maxillofacial region often result in discontinuity defects of peripheral branches of the trigeminal (fifth cranial) nerve, causing loss of sensation to those areas of the face, mouth, or jaws supplied by this important nerve. Injuries to the peripheral branches of the trigeminal nerve can be repaired by microsurgical techniques, either at the time of the original injury or ablative operation if conditions are favorable, or at a later date. Repair of a peripheral nerve injury has a good chance of a satisfactory outcome if done in a timely fashion., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose of Review: Twenty-one face transplants have been performed to date. This review provides an overview of the clinical outcomes and the lessons learned from these initial cases., Recent Findings: Facial transplantation has progressed over the past 10 years from an experimental possibility to a clinical reality. The most recent transplants performed in the USA, Spain and Turkey involve the full face. Good sensory recovery of the allograft has been consistently reported, even in the absence of nerve repair. As predicted, motor recovery has been slower than re-innervation of sensation. Dramatic improvements to functional status have been seen, with recipients regaining the ability to smile, smell, eat, drink and speak. Episodes of acute rejection have been common and controlled with increases in systemic immunosuppression. The first face transplant recipient is now over 5 years after surgery. Chronic rejection has not been seen in her or any other case. Despite the encouraging outcomes, complications because of immunosuppression, including malignancy, have occurred., Summary: The outcomes of facial transplantation thus far have been very encouraging. The development of standardized tools to measure functional and psychological outcomes is required as more cases are performed. We recommend that facial transplantation is still only to be performed by experienced multidisciplinary teams.

Purpose: The objectives of this study were to determine the likelihood of regaining functional sensory recovery (FSR) after microsurgical repair of the inferior alveolar nerve (IAN), and which variables significantly affected the outcome of that surgery in a large series of patients., Materials and Methods: This was a retrospective cohort study that evaluated all patients who had undergone microsurgical repair of the IAN by 1 of the senior surgeons (R.A.M.) from March 1986 through December 2005. The requirements for inclusion of a patient in the study included the availability of a complete chart record and a final follow-up visit at least 12 months after surgery. All other patients were excluded. The predictor variables were categorized as demographic, etiologic, and operative. The final outcome variable was the level of recovery of sensory function as determined by standardized neurosensory testing at the last postoperative visit of each patient and based on guidelines established by the Medical Research Council Scale. Risk factors for surgical failure to achieve useful sensory function were determined from analysis of descriptive statistics, including patient age, patient gender, etiology of nerve injury, chief sensory complaint (numbness, pain, or both), time from injury to surgical intervention (in months), intraoperative findings, and surgical procedure. Logistic regression methods and associated odds ratios were used to quantify the association between the risk factors and improvement. Receiver operator characteristic curve analysis was used to find the threshold of those variables that significantly affected patient outcome., Results: In total, 167 patients (41 male and 126 female patients; mean age, 38.7 years [range, 15-75 years]) underwent 186 IAN repairs (19 patients sustained bilateral IAN injuries). The mean time from injury until surgery was 10.7 months (range, 0-72 months). Successful recovery from neurosensory dysfunction (FSR, defined by the Medical Research Council Scale as ranging from useful sensory function to complete sensory recovery) was observed in 152 repaired IANs (81.7%). With increasing duration from date of injury to IAN repair, the likelihood of FSR decreased (odds ratio, 0.898; P < .001). The odds of achieving FSR exhibited a linear decline between the date of nerve injury and its repair, with a significant drop in rate of successful outcome (FSR) occurring beginning at 12 months after injury. There was also a significant negative relationship between increasing patient age and improvement (odds ratio, 0.97; P = .015), with a threshold drop of achieving FSR at 51 years of age. The cause of the injury, the operative findings, and the type of operation performed to repair the nerve had no significant effect on the likelihood of the patient regaining FSR. The presence of pain after nerve injury did not affect the likelihood of achieving FSR after repair in a statistically significant manner (P = .08). In those patients who did not have pain as a major complaint before nerve repair, pain did not develop after microneurosurgery., Conclusions: Microsurgical repair of an IAN injury resulted in successful restoration of an acceptable level of neurosensory function (FSR) in most patients (152 of 186 repairs [81.7%]) in this study. The likelihood of regaining FSR was inversely related to both time between the injury and its repair and increasing patient age, with significant threshold drops at 12 months after nerve injury and at 51 years of age, respectively., (Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Damage to peripheral nerves causes significant remodeling of peripheral innervation and can lead to neuropathic pain. Most nociceptive primary afferents are unmyelinated (C fibers) and subdivided into peptidergic and nonpeptidergic fibers. Previous studies have found nerve injury in the trigeminal system to induce changes in small-diameter primary afferent innervation and cause significant autonomic sprouting into the upper dermis of the lower-lip skin of the rat. In this study, we used the ribosomal toxin, saporin, conjugated to the lectin IB4 to specifically ablate the nonpeptidergic nociceptive C fibers, to see if loss of these fibers was enough to induce autonomic fiber sprouting. IB4-saporin treatment led to specific and permanent ablation of the IB4-positive, P2X(3)-immunoreactive fibers and led to sprouting of parasympathetic fibers into the upper dermis, but not of sympathetic fibers. These changes were associated with significant increase in glial-derived nerve growth factor levels in the lower-lip skin. While IB4-saporin treatment had no effect on evoked mechanical thresholds when von Frey hairs were applied to the lower-lip skin, ablation of nonpeptidergic fibers in a chronic constriction injury model caused significant sympathetic and parasympathetic fiber sprouting, and led to an exacerbated pain response. This was an unexpected finding, as it has been suggested that nonpeptidergic fibers play a major role in mechanical pain, and suggests that these fibers play a complex role in the development of neuropathic pain., (Copyright © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to evaluate whether the recombinant human nerve growth factor (rhNGF-β) gene transfer at a crush-injured sensory nerve can enhance nerve regeneration., Study Design: A 4-mm crush injury was made on the mental nerve of mandible in rats, and rhNGF-β adenovirus (6 μL, concentration = 1.0 × 10(11) pfu/μL) was injected at the crushed site for the experimental group (NGF-Ad group, n = 15) and the same volume of PBS for the controls (PBS group, n = 15). A sham group of uninjured nerve was also used for the normal control (Sham group, n = 15). The effect of rhNGF-β adenovirus injection was evaluated by real-time reverse trascriptase polymerase chain reaction for the quantification of nerve growth factor (NGF), low-affinity NGF receptor (p75NTR), and its tyrosine receptor kinase A (trkA) mRNA expression at the trigeminal ganglion (TG) 5 days after injection. Nerve regeneration was evaluated with sensory test, retrograde axonal transport in the TG, and histomorphometric study for 4 weeks., Results: NGF, p75NTR, and trkA mRNA expression was significantly increased at the TG 5 days after injection of rhNGF-β adenovirus (P < .05). The NGF-Ad group showed improved sensory recovery (P < .05), and the number of retrograde-labeled sensory neurons and soma size of TG were larger compared with the PBS groups (P < .05). Histomorphometrically, the myelinated axon number, myelin thickness, and G-ratio in the NGF-Ad group was also significantly higher than the PBS groups (P < .05)., Conclusions: Recombinant human nerve growth factor gene transfer promoted regeneration of crush-injured mental nerve., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To report a new approach to lower lip reanimation, which can be performed in the outpatient clinic setting., Study Design: Cross-sectional study., Setting: Tertiary and quaternary care academic hospital, Toronto., Subjects and Methods: An evaluation of nine patients with marginal mandibular nerve injury, who underwent harvest of the palmaris longus tendon and static suspension of the lower lip, was performed in the outpatient setting. Outcome measures included subjective self-evaluation of the functional and aesthetic results using the Lip Reanimation Outcomes Questionnaire and postoperative photographic grading of symmetry at rest and during three smile poses. Medical records were reviewed for demographics and complications., Results: Seventy-eight percent of patients reported overall improvements in smiling, oral competence, and speech articulation following tendon transfer. Photographic grading by the judging panel found satisfactory smile symmetry postprocedure., Conclusions: The palmaris longus tendon sling procedure provides an effective, additional option for reanimation of the paralyzed lower lip.

Object: In large vestibular schwannomas (VSs), microsurgery is the main treatment option. A wait-and-scan policy or radiosurgery are generally not recommended given concerns of further lesion growth or increased mass effect due to transient swelling. Note, however, that some patients do not present with symptomatic mass effect or may still have serviceable hearing. Moreover, others may be old, suffer from severe comorbidity, or refuse any surgery. In this study the authors report the results in patients with large, growing VSs primarily treated with Gamma Knife surgery (GKS), with special attention to volumetric growth, control rate, and symptoms., Methods: The authors retrospectively analyzed 33 consecutive patients who underwent GKS for large, growing VSs, which were defined as > 6 cm(3) and at least indenting the brainstem. Patients with neurofibromatosis Type 2 were excluded from analysis, as were patients who had undergone previous treatment. Volume measurements were performed on contrast-enhanced T1-weighted MR images at the time of GKS and during follow-up. Medical charts were analyzed for clinical symptoms., Results: Radiological growth control was achieved in 88% of cases, clinical control (that is, no need for further treatment) in 79% of cases. The median follow-up was 30 months, and the mean VS volume was 8.8 cm(3) (range 6.1-17.7 cm(3)). No major complications occurred, although ventriculoperitoneal shunts were placed in 2 patients. The preservation of serviceable hearing and facial and trigeminal nerve function was achieved in 58%, 91%, and 86% of patients, respectively, with any facial and trigeminal neuropathy being transient. In 92% of the patients presenting with trigeminal hypesthesia before GKS, the condition resolved during follow-up. No patient- or VS-related feature was correlated with growth., Conclusions: Primary GKS for large VSs leads to acceptable radiological growth rates and clinical control rates, with the chance of hearing preservation. Although a higher incidence of clinical control failure and postradiosurgical morbidity is noted, as compared with that for smaller VSs, primary radiosurgery is suitable for a selected group of patients. The absence of symptomatology due to mass effect on the brainstem or cerebellum is essential, as are close clinical and radiological follow-ups, because there is little reserve for growth or swelling.

Objective: The aim of this study was to introduce a new inferior alveolar nerve (IAN) defect repair method that does not require a nerve graft., Study Design: The IAN was isolated after removal of a buccal cortical window. The scarred area or neuroma caused by the dental implant was excised with fresh cut ends and an epineural margin. If the excised gap was too wide for direct closure, the incisive nerve was intentionally transected 5 mm anterior to the mental foramen to obtain sufficient posterior mobilization of the distal stump of the IAN. The nerve ends were then approximated directly by sliding the distal nerve end to the proximal cut end. After completing the nerve repair by using four 10-0 nylon epineural sutures, the cortical window was repositioned with a microplate and screws., Results: Using this technique, 3 nerve repairs without a nerve graft were successfully achieved for gaps ∼10 mm in size., Conclusions: The great advantage of this technique is that a moderate nerve defect can be anastomosed without a nerve graft when direct closure of the nerve segment is impossible without tension., (Copyright © 2011 Mosby, Inc. All rights reserved.)