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Nerve Injuries.dr.Sangram. (NXPowerLite) / orthodontic courses by Indian dental academy
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Transcript of Nerve Injuries.dr.Sangram. (NXPowerLite) / orthodontic courses by Indian dental academy
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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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NERVE INJURIES
NERVE: Nerves are solid white cords made up of bundles of axons
• Each nerve fiber is known as an axon
• Each axon is bound by fibrous tissue into small bundles
The nerve trunk is composed of 4 connective tissue sheaths from
outside inwards are:www.indiandentalacademy.com
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1.Mesoneurium: Suspends nerve within soft tissue and provides segmental blood supply to it.2.Epineurium: Protects nerve from mechanical stress3.Perineurium4.Endoneurium• Group of nerve fibers- FASCICULI• Each FASCICULI is surrounded by PERINEURIUM• Group of FASCICULI forms a NERVE TRUNK• FASCICULES are surrounded by EPINEURIUM
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Etiology of Nerve injuries:a. LOCAL CAUSES• Facial bone fractures.• Treatment of oral pathological conduction.• Maxillofical reconstructive surgery.• Removal of impacted lower third molar.b. CENTRAL DISEASES
- Syringomyelia - Multiple Sclerosis - Bulbar Paralysis
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Classification of Injuries:In 1943 SEDDON introduced a classification of nerve injury based on three types of nerve fiber injury. 1. Physiologic Disruption NEUROPRAXIA, 2. Axonal disruption AXONOTEMESIS, 3. Division of the nerve NEURONOTEMESIS.
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Neuropraxia:
1. Least severe form of peripheral nerve injury, 2. Result of contusion of the nerve ( continuity of
epineurial sheath and axons maintained.3. Blunt trauma, traction stretching of nerve,
inflammation or local ischemia 4. Full recovery of the nerve function within few
days or weeks.
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Axonotmesis:
Blunt trauma, nerve crushing, extreme traction of nerve. • Afferent fibers degenerate but nerve trunk intact, no disruption of endo/peri/Epineurium• Recovery is good but incomplete (2, 4-12month)
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Tinnel’s sign:
Painful, electric shock like sensation elicited by tapping directly over the cutaneous distribution of injured nerve
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Neurotmesis:
Severe disruption of connective tissue component of nerve trunk. ( Loss of nerve continuity) Prognosis for recovery poor
Sensory recovery is not expected when nerve in soft tissue, but if within canal minimal recovery expected www.indiandentalacademy.com
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SUNDERLAND (based on degree of tissue injury)Five degrees based on increasing anatomic severity of injury.Classification DescriptionGrade I Loss of axonal conductionGrade II Loss of axonal ContinuityGrade III Loss of axonal and endoneurial
continuity Grade IV Loss of perineurial continuity with
fascicular disruptionGrade V Loss of continuity of entire nerve
trunkwww.indiandentalacademy.com
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COMPARTMENT SYNDROME:
• Local increase in pressure (edema/venous stasis) causing decreased oxygenation.
• Abnormal vibration and touch perception
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TESTING FOR NERVE INJURY:
1. Light touch: cotton wisp2. Two-point discrimination: >10mm abnormal3. Localization4. Sharp blunt differentiation5. Thermal stimuli: 150c to 500c
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BASIC PRINCIPLES OF NERVE REPAIR:1. Decompression:2. Neurorraphy: (Gap of 10mm only)
a. Preparation of nerve stumpsb. Approximationc. Cooptatione. Maintaining the cooptation
3. Nerve Grafts:- Sural nerve- Greater auricular nerve
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TRIGEMINAL NEURALGIA
Synonyms:· Tic douloureux- spasmodic contraction of facial muscles · Fother gill’s disease
· Trifacial neuralgia
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Definition:
‘A painful unilateral affliction of the face, characterized by brief electric shock like (lancinating) pain limited to the distribution of one or more divisions of the trigeminal nerve’
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PREVIOUSLY CLASSIFIED AS:
1. Classical trigeminal neuralgia or Idiopathic trigeminal neuralgia
2. Specific trigeminal neuralgia (known etiology) Pre- trigeminal neuralgia (PTN
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INCIDENCE: Female affected more than males (3:2) Right > left Middle age and elderly 4% Bilateral 95% Maxilla + Mandibular nerve involved 5% Ophthalmic nerve involved
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CLINICAL FEATURES:
“WHITE AND SWEETS CRITERIA”1. PAIN: Paroxysmal (lasts from few seconds to few minutes)
Extremely intense (stabbing/ lightening/ pricking/ knife like)
Pain free episodes/ intervalswww.indiandentalacademy.com
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2. TRIGGER ZONES:
Vermilion/ alae/ cheeks/ periorbital area Cutaneous in distribution Stimuli includes- touch/ breeze/ talk/ chew/brush/shave
3. PRE-TRIGEMINAL NEURALGIA(PTN): Mild, lancinating/pricking type Months to years before chronic type of trigeminal neuralgia
4. HYPERESTHESIA/ HEPERALGESIA On routine clinical examination
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5. ALWAYS UNILATERAL:If bilateral, then only one side affected at a time
Unshaven and unclean face (frozen face) Spontaneous remission is unusual Attacks do not occur during sleep(characteristic) Secondary radiation of pain to adjacent division
HYPOTHESIS:1. Neural back talk theory – secondary to nerve injury2. Deafferentation of central processes due to peripheral injury
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CLINICAL FEATURES: Male = female Middle age or late life Pain: lancinating pain of oropharynx or neck, lasts for week-months Triggered by swallowing/ cough/ talk Unilateral & radiates to ear & or mouth Syncope is a feature Rarely causes xerostomia/excess salivation Disturbs sleep
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ETIOLOGY:
1. C-P angle tumors: Acoustic Neuroma/ Cholesteotoma/ Meningioma/ Osteoma/ Angioma2. Anatomical variation of Petrous bone/ridge3. Aneurysms and Adhesions4. Multiple Sclerosis
INVESTIGATIONS: Nerve functions- sensory and motor (trigger zones)Diagnostic nerve blocksSpecial tests for tumors and systemic diseases
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Treatment modalities:Medical:(A)1. Phenytoin sodium (dilantin) 200-600mg/day in divided doses2. Carbamazepine (tegretol/ carbital) Initially – 100mg BID Increase to 200mg TID 3. Max. Dose is 1200mg/day in divided doses Baclofen or l-baclofen (lioresal) 10-80-mg/ day in divided doses4. Valproic acid (depakote) 125-250 mg/day5. Clonazepam (klonopin) 0.5 - 8mg/day6. Pimiozide (orap) 2-12 mg/day7. Lamotragine (lamicital) 50-100mg/day
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(B) PERCUTANEOUS injections:(2days -1-week interval)
Chemicals used: local anesthesia/ absolute alcohol/ phenol-
glycerin mixture
Injection site: peripheral nerves/trigger zones/gasserian ganglion
(C) percutaneous electro-coagulation
(D) cryosurgery (-900 to –1600 c)
(E) ratners procedure/ osseous curettage
Bone decortication+curettage+triple antibiotic pack
(chloromphenicol+tetracycline+iodoform)www.indiandentalacademy.com
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TREATMENT:
▪ Medical: - Carbamazepine/ Phenytoin/ Baclofen▪ Local: - Cryotherapy/ Alcohol Injection▪ Surgery: - Section GPN & Upper Rootlets Of Vagus▪ Central: - Micro vascular Decompression
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Thank you
For more details please visit www.indiandentalacademy.com
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