Damage to the mandibular nerve during implantation

Causes

The main causes of damage to the NAS are:

implantation (doctor’s errors, lack of a full preliminary examination);
removal of dystopic “eights” on the lower jaw;
errors when performing conduction anesthesia;
exit of the filling material beyond the root apex into the nerve canal;
infectious lesion of the periapical region of the lower row.

But the most common reason is the first reason - damage as a result of implant installation, usually in the chewing area.

Forehead area: nerve anatomy

Knowing where the nerves are located in the highly sensitive area of the forehead is important to ensure not only safety, but also patient comfort during the procedure.

The following are subject to anesthesia:

supraorbital nerve;
supratrochlear nerve.

The supraorbital nerve is one of the terminal cutaneous branches of the frontal nerve, which in turn arises from the ophthalmic branch of the trigeminal nerve. N. supraorbitalis provides sensitivity to the forehead and anterior scalp.

The supratrochlear nerve originates from the supraorbital notch, which can be identified by palpation in the area of the supraorbital margin.

First signs of damage

The first symptoms of nerve damage are discomfort in the gums, cheeks, and lower lip. Manifestations of the problem are:

paresthesia, that is, a change in the level of sensitivity without pain;
dysesthesia with pain in the affected area, a feeling of “pins and needles”, changes in the general sensitivity of the area;
anesthesia - complete loss of sensation in a certain area.

In some cases, the lingual nerve, which runs from the side of the tongue into the gum tissue, may be affected. This is usually observed as a result of the removal of "eights" (in approximately 2.1% of all cases). When implanted, this nerve is affected less frequently. If this situation occurs, the following symptoms appear:

salivation becomes profuse;
involuntary biting of the tip of the tongue appears;
diction disorders;
burning sensation, numbness in the tongue;
loss, change in taste;
swallowing is impaired.

In 90% of cases, the problems go away on their own within seven to ten weeks; no special treatment is required.

Why is the facial nerve damaged?

For this disease, predisposing factors and triggering points can be identified. Predisposing factors are systemic diseases of internal organs in which metabolism or metabolism is perverted. These are diabetes mellitus and arterial hypertension. Elderly people are also at risk. Sometimes the facial nerve is damaged in pregnant women, especially with toxicosis. In people with metabolic disorders, neuropathy of the facial nerve can occur without external visible causes. In this case, it is called secondary and is considered as a complication of the underlying disease. Treatment begins with compensation for those metabolic disorders that provoked neuropathy.

In healthy young people, the onset of neuropathy may be caused by hypothermia. This option is characterized by seasonality, beginning in the cold season.

The leading cause of facial neuropathy is:

of unknown cause or idiopathic, also known as Bell's palsy - it accounts for up to 70% of all visits in the autumn-winter season;
otogenic (literally “originating from the ear”), which occurs after inflammation of the middle ear or mastoid process of the temporal bone;
infectious - a rare disease, which is most often caused by herpes, but can be caused by tuberculosis, mumps, syphilis or other infections;
traumatic – cases of nerve damage due to traumatic brain injury are known;
ischemic – when blood flow in the vessels supplying the nerve is disrupted.

The acute stage of facial nerve neuropathy lasts up to 2 weeks, subacute - up to a month, chronic - longer than 1 month.

Classification

In accordance with Seddon's classification, the following types of NAS injuries are distinguished:

Neuropraxia. This injury is reversible; the sheath of the nerve fibers does not suffer, that is, there is no development of degeneration. After treatment, the problem goes away, which usually takes a couple of weeks.
Axonotmesis. A reversible type of lesion, for which long-term, intensive treatment is prescribed - from three to six months. The development of degeneration and fiber damage are observed.
Neurotmesis. A serious disorder affecting all structures, including fibers and connective membranes. Scar tissue develops, and surgery is indicated to correct the problem.

In accordance with the generally accepted WHO classification, there are five categories of NAS injuries:

compression, nerves are not damaged;
swelling of tissues;
partial rupture of fibers;
complete ruptures of the NAS are observed;
post-traumatic fibrosis develops.

Assessment methods

To determine the cause and extent of the disorder, diagnostics are required. For this purpose they prescribe:

mechanoceptive methods, in which the response to mechanical irritation and stimulation is recorded;
nociceptive, allowing to determine sensitivity to painful stimulation.

The first type of research includes tests of the following types:

tests with a brush, during which the Patient’s lip is passed with a brush and asked to determine the direction of movement;
two-point irritation using a probe.

The second diagnostic method includes:

pin tests;
Temperature tests for sensations of cold or heat.

Tests are also carried out for the presence of deficits in the sense of taste, and data from the right and left sides of the maxillofacial apparatus are compared. The accuracy of the research should be no more than 1 mm.

Treatment

The following regimens are used for therapy:

observation of the Patient at intervals of 2, 3, 4, 6 months;
drug therapy;
unscrewing, removing the implant;
microsurgical intervention.

There is no strict protocol; tactics are determined individually in each case. But there are limitations to surgical intervention - it will be effective only in the first year, after which this method is considered ineffective.

Drug therapy includes:

taking painkillers;
use of hydrogen pump blockers;
prescription of anti-inflammatory drugs (glucocorticosteroids are prescribed);
therapy for sensory impairment.

If symptoms appear in the first 1.-1.5 days after installation of the implant, its removal may be indicated. During this period, the prognosis is favorable, but over a longer period of time, removing the artificial root will no longer bring a noticeable improvement. The reason is irreversible changes in nerve fibers.

Surgery is indicated in cases where all previous measures have not brought the expected effect. To do this, the doctor must determine the location of the NAS and evaluate sensitivity disorders. The effectiveness of the operation is influenced by the following factors:

time between injury and surgery;
severity, type of lesion;
blood supply;
Preparation;
tension zone;
Patient's age, health status.

Predictions and prevention

Treatment has an uncertain prognosis; with microsurgical intervention, the positive result is in the range of 55-82%. If the damage is severe, complete recovery does not occur with any treatment method. According to some experts, complications such as pain persist even after the intervention. It is also worth noting that the success of treatment depends entirely on the extent of the lesion. It is impossible to guarantee a high result in any situation, that is, the forecasts are uncertain.

To avoid complications, prophylaxis is recommended. This is a mandatory full examination before the implantation procedure. The specialist will determine the exact location of the nerve, the topography of the nerve trunks and the maxillofacial system. This allows you to exclude the development of pathology and conduct conduction anesthesia correctly, without the risk of complications.

The main preventive measures include:

competent selection of implantation system;
diagnostics, including CT, production of a surgical template, computer modeling;
planning the procedure for introducing an artificial root;
determining the paths of nerve trunks, ensuring the distance between them and implants is not less than 2 mm;
when drilling, it is necessary to avoid excessive force;
When immersing a drill or implant, stoppers are used to limit the depth and ensure safety.

Treatment of damage to the mandibular nerve during implantation requires the doctor to have high qualifications and experience. But even under such conditions, the success rate does not exceed 82%. Some complications may remain, such as numbness or soreness.

Trigeminal nerve

Trigeminal nerve: symptoms of inflammation and treatment methods

Inflammation of the trigeminal nerve does not threaten the patient’s life, but becomes a real test of fortitude.
The disease is accompanied by painful symptoms and significantly impairs the quality of life. Anxious anticipation of paroxysms of trigeminal neuralgia provokes depression, and some people experience suicidal thoughts. Insomnia is a typical condition for this pathology, which can be caused by both severe pain and deterioration of the emotional background. Among the accompanying changes are decreased performance, fatigue, and frequent headaches. The publication discusses the main causes of trigeminal neuralgia, clinical signs and features of diagnosing the disease, and the main methods of medical and surgical care. The possibilities and methods of treating trigeminal neuralgia using physiotherapeutic methods and folk remedies will be considered.

Trigeminal Nerve: Relationship Between Anatomy and Symptoms

The trigeminal facial nerve forms the fifth pair of cranial nerves (cranial nerves). It contains not only afferent sensory fibers, but also motor fibers. Sensory fibers provide superficial and proprioceptive (deep) sensitivity and transmit information to the brain from the skin of the entire face, mucous membranes of the eyes, nose and mouth, muscle and connective tissue structures, teeth and bones of the facial skeleton. Motor fibers go to the masticatory muscles.

Nervus trigeminus received its name due to the peculiarities of its anatomical structure. It is formed by three branches. The first is the orbital nerve. The second is called the maxillary nerve, and the third is the mandibular nerve.

The orbital, also the first branch of the nervus trigeminus, contains only sensory fibers. There are no motor neurons in its composition. The innervation zone includes the frontal zone, temples, eyebrow, upper eyelid, cornea and conjunctiva. Accordingly, with neuralgia of the ophthalmic branch, pain, numbness of the skin and paresthesia are localized in the forehead, eyebrows and eyelids. There may be a weakening or loss of reflexes, the adductor arc of which passes as part of the superior branch (suprabrow reflex, corneal reflex).

The second branch, like the first, contains exclusively sensory afferent fibers. The endings of sensory neurons are directed to the cheekbones and cheeks, wings and back of the nose, and lower eyelids. They also transmit signals from the mucous membrane of the nasal passages, maxillary bone, upper lip and upper teeth. With neuralgia of the second branch, pain, numbness of the skin and paresthesia are concentrated in the central part of the face on the right or left (the pain is always one-sided). Pain in the teeth of the upper row is typical.

The third branch, or mandibular nerve, contains not only sensory fibers, but motor (motor) neurons. This branch transmits information from the lower part of the face - the chin and mandibular bone, teeth, lower lip. Motor fibers transmit signals and coordinate the movements of many masticatory muscles and their antagonists. Also, the efferent fibers of the inferior branch go to the temporal muscle.

When the mandibular branch of the trigeminal nerve is affected, the epicenter of pain, skin numbness, hyperesthesia and paresthesia is located in the lower third. One of the symptoms is weakening or loss of the mandibular reflex. And since the lower branch also contains axons of motor neurons, an attack of neuralgia can be accompanied by motor disorders - spasm or paralysis of the muscles of the masticatory group and their antagonists.

Causes of trigeminal neuralgia

The pathogenesis of trigeminal neuralgia involves compression of one of its branches. The cause of root compression may be infection and inflammation, abnormal location or pathology of blood vessels; less commonly, the cause of compression is a tumor. Trigeminal neuralgia can be a symptom of multiple sclerosis. The following changes in the body and pathological conditions contribute to the development of inflammation of the trigeminal nerve:

Hypothermia.
Acute or chronic stress.
Weakening of the immune system.
Nervous fatigue and exhaustion.
Hormonal imbalances.
Chronic sinusitis, frontal sinusitis.
Vascular pathology.
Head injuries.
The presence of foci of chronic infection in the body.

Very often, the true cause of trigeminal neuralgia is diseases of the oral cavity and teeth. In this regard, odontogenic inflammation of the trigeminal nerve is separately distinguished, which is secondary, and the cause of which is dental pathology. With single-gene neuralgia, as a rule, the maxillary or mandibular branch is affected, and among the symptoms of the disease there is a painful toothache.

Note. In 95% of cases with neuralgia n. trigeminus affects the 2nd or 3rd branches! This indicates a close connection between pathology and dental diseases.

Odontogenic neuralgia of the trigeminal nerve develops with the following dental diseases and anomalies of the development of the dentofacial system:

Caries.
Pulpitis.
Periodontal disease, inflammation of periodontal tissue.
Gingivitis.
Osteomyelitis of the jaw bone.
Retained and dystopic teeth.
Poor quality dentures.

If you have inflammation of the trigeminal nerve, you must undergo an examination by a dentist to identify the above and other dental diseases. It is extremely important to sanitize foci of chronic infection - cure pulpitis, periodontitis, treat carious teeth, remove retained and dystopic teeth, replace low-quality orthopedic structures (prostheses).

For many patients, oral sanitation has helped to completely cure inflammation of the trigeminal nerve. It is also necessary to undergo an examination by an otolaryngologist, diagnose the paranasal sinuses, and treat chronic sinusitis or sinusitis.

Trigeminal nerve: clinical picture of the disease

The key clinical sign of inflammation of the trigeminal nerve is severe pain. The specifics of pain (localization, character) may differ, but one thing remains unchanged. The pain is always excruciating. Paroxysmal attacks “paralyze” and knock you out of the usual rhythm of life. They can be short-term, lasting no more than a few minutes, and the pain in this case is often shooting in nature. The second option is a constant burning, drilling or cutting pain that exhausts a person for 2-3 days.

Any manipulation on the face can provoke a paroxysm of neuralgic pain. Women, who for some unknown reason suffer much more often from this disease, often provoke a paroxysmal attack by applying decorative cosmetics, and men by shaving. The trigger factor for an attack of trigeminal pain can be even a normal conversation, washing with cool water, or hygiene procedures for caring for the oral cavity or facial skin.

Triggers are actions that provoke the return of paroxysmal pain. They are, as a rule, preceded by some events that happened shortly before that affected the general condition of the body. The true cause of exacerbation of inflammation of the trigeminal nerve can be hypothermia, exacerbation of herpes, colds, nervous fatigue and stress, even eating certain foods (fatty, spicy foods, chocolate, garlic).

The localization of pain depends on which branch is affected by the pathological process. With compression and inflammation of the orbital branch, pain in the upper third of the face dominates in the clinic; with damage to the middle root - in the upper jaw, upper teeth, and cheekbones. When the lower branch is compressed, the epicenter of pain is often localized in the teeth of the lower jaw. In addition, inflammation of the third branch is characterized by motor disturbances - spasm or paralysis of the masticatory muscles on the affected side.

Since the trigeminal nerve innervates one half of the face, pain, paresthesia and motor disorders are always unilateral. The patient complains of pain only on the right or only on the left. Because of this, slight or pronounced facial asymmetry often develops. With neuralgia of the lower branch, there may be a weakening of the bite on the affected side.

The trigeminal nerve contains sensory fibers that are part of the adductor arc of some reflexes. In this regard, with this disease, a decrease or loss of superciliary, corneal or mandibular reflexes is often observed. This symptom is detected during an examination of the patient by a neurologist.

Diagnostics

A preliminary diagnosis of inflammation of the trigeminal nerve is made by a neurologist based on the clinical picture, which includes:

attacks of acute pain of a burning or shooting nature;
unilateral localization of pain;
numbness of the skin, tingling sensation or “pins and needles” on the affected side;
weakening of reflexes;
motor disorders with damage to the 3rd branch of the trigeminal nerve;
vasomotor and secretory disorders (lacrimation, increased salivation).

To confirm the diagnosis, identify the cause of the disease, accurately determine the location of compression and differential diagnosis with other neurological diseases, instrumental examinations are prescribed:

Computed tomography or MRI of the brain.
X-ray of the facial skeleton.
Angiography.
Electromyography.
Other.

Inflammation of the trigeminal nerve: treatment methods

The main objectives in the treatment of the trigeminal nerve are pain relief and complete cessation of paroxysms of neuralgic pain. To solve the problems, therapeutic and surgical approaches are used, as well as massage and physiotherapy. Treatment with folk remedies can be used as an additional, but not the main method.

Drug therapy

Drug treatment is carried out using strong painkillers, as well as anti-epileptic drugs. Carbamazepine, an anticonvulsant, helps relieve pain. Muscle relaxants and anti-neurotic drugs may be included in treatment regimens. In severe cases, narcotic analgesics are prescribed.

Painkillers from the NSAID group are ineffective for trigeminal neuralgia. Only the attending physician can prescribe strong analgesics and other drugs, and therefore the patient should contact a qualified specialist as soon as possible.

To reduce swelling and inflammation, hormones from the group of corticosteroids (Diprospan, Hydrocortisone) are included in the treatment protocols for the trigeminal nerve. Corticosteroids have a strong anti-exudative (anti-edematous) and anti-inflammatory effect, due to which rapid positive dynamics are achieved. Antihistamines can be used as an additional antiexudative and anti-inflammatory agent.

Neuroprotectors are also used in treatment to improve the nutrition of nerve cells and promote their recovery. If there are foci of chronic infection, antibiotics are prescribed. When exacerbation of labial herpes occurs, antiviral drugs are prescribed. Treatment regimens often include vitamin injections, vascular medications, antidepressants, tranquilizers and sedatives.

Rehabilitation of foci of chronic infection is mandatory. It is necessary to undergo diagnostics at the dentist, treat existing diseases of the teeth (caries, pulpitis), gums and periodontal tissues. If the diagnosis of neuralgia reveals chronic sinusitis, you need to undergo treatment from an otolaryngologist.

Surgery

In cases where the cause of paroxysmal attacks is compression of the root by a tumor or pathologically altered vessel, surgical treatment is performed. Its goal is to decompress nerve fibers, which is achieved by removing a tumor or moving a blood vessel. For decompression purposes, the nerve root can be isolated from surrounding tissues using a special protective sleeve.

If decompression is impossible or ineffective, surgical treatment has a different goal - complete cessation of impulse transmission along the fibers of the affected nerve. For this, a radiosurgery method can be used, which involves destruction of the sensory nerve, radiofrequency rhizotomy (destruction of the root using electromagnetic influence) or balloon compression.

Additional treatments

Additional methods of therapy include massage, physiotherapy and folk remedies. Massage improves blood circulation and helps reduce swelling, which increases nerve compression during inflammation. Physiotherapeutic procedures include electro- and phonophoresis, ultrasound, pulsed currents, and electromagnetic pulses. Reflexology can have a good effect.

At home, you can use the following traditional medicine recipes:

Rinse your mouth with a decoction or infusion of chamomile. Rinsing has a minor effect in case of infectious etiology, but does not have an analgesic effect.
Rubbing fir oil into the area of most severe pain. Can be repeated several times throughout the day to slightly reduce pain. It will not be possible to completely relieve the pain syndrome.
Rubbing the skin of the affected area of the face with black radish juice. Has a weak analgesic effect.
Healing clay: apply medicinal clay diluted in vinegar to the affected area. Used as an anti-inflammatory agent.
Apply marshmallow infusion compresses to the painful area of the face for 30 minutes 1-2 times a day.

The trigeminal nerve is located deep, and traditional medicine cannot have a direct effect on inflamed and swollen tissues. The measures listed above are mainly distracting and auxiliary in nature; they cannot significantly alleviate the patient's condition. Therefore, if trigeminal neuralgia worsens, you should seek qualified help as soon as possible.

You can learn more about the methods of treating neuralgia and inflammation of the trigeminal nerve at the Galaktika clinic (Moscow).

Anatomy of nerves in the temporal region

In the context of injection facial correction, it is customary to distinguish several planes. For contouring, the technique most often used is to inject fillers into the space between the temporalis muscle and the bone of the temporal fossa . Injecting the drug into the specified plane in the superomedial area of the temple minimizes the risk of vascular complications, as well as damage to the zygomaticotemporal nerve.

Rice. 1: facial nerves and deep fat compartments

Fillers are also injected:

between the superficial and deep layers of the deep temporal fascia.
between the deep temporalis fascia and the temporalis muscle.

For patients with severe volume deficit in this area, filler is injected into the space between the superficial temporal fascia and the deep temporal fascia . Here the doctor works only with a cannula - this reduces the risk of damage:

superficial temporal artery and vein;
frontal branch of the facial nerve.

To prevent damage to neurovascular structures in this plane, the author uses a 22-gauge cannula.