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SPRING WEBINAR WITH DR. BRUCE DONOFF
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Transcript of SPRING WEBINAR WITH DR. BRUCE DONOFF
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Inferior Alveolar and Inferior Alveolar and Lingual Nerve InjuriesLingual Nerve Injuries
Algorithms for ManagementAlgorithms for Management
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Scenarios of Nerve InjuryScenarios of Nerve InjuryInferior Alveolar NerveInferior Alveolar Nerve
OdontectomyOdontectomy Following injectionFollowing injection Following endodonticsFollowing endodontics Following implantsFollowing implants Following genioplasty with or without Following genioplasty with or without
BSSOBSSO
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Scenarios of Nerve InjuryScenarios of Nerve InjuryLingual NerveLingual Nerve
OdontectomyOdontectomy Periodontal surgeryPeriodontal surgery Following injectionFollowing injection Screws of BSSO fixationScrews of BSSO fixation
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Tests of Nerve InjuryTests of Nerve Injury
MappingMapping Mapping with tactile, thermal and pulp Mapping with tactile, thermal and pulp
stimulationstimulation Serial tactile and thermal testsSerial tactile and thermal tests Clinical test algorithms with tactile and painful Clinical test algorithms with tactile and painful
stimulistimuli Somatosensory evoked potentialsSomatosensory evoked potentials MicroelectroneurographyMicroelectroneurography Electronic thermographyElectronic thermography Taste with vital staining-videomicroscopyTaste with vital staining-videomicroscopy Magnetic source imagingMagnetic source imaging
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The Five Radiographic SignsThe Five Radiographic Signs11
Fig. 1: Darkening of the Root Fig. 2: Deflection of the Roots Fig. 3: Interruption of White Line
Fig. 4: Diversion of the IA Canal Fig. 5: Narrowing of the Root
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Radiographic Risk FactorsRadiographic Risk FactorsX-ray X-ray findingfinding
SensSens(%)(%)
SpecSpec(%)(%)
PPVPPV(%)(%)
NPVNPV(%)(%)
PPVPPV(%)(%)
NPVNPV(%)(%)
DiversionDiversion 5050 8282 3434 8989 2.72.7 9999
DarkeningDarkening 6565 7373 3131 9393 2.32.3 9999
InterruptionInterruption 8080 5454 2525 9393 1.71.7 9999
Any findingAny finding 100100 3333 2222 100100 1.41.4 100100
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Case for Early RepairCase for Early Repair
Animal studies – most support early Animal studies – most support early repair, but some success laterepair, but some success late
Humans – difficulty comes from Humans – difficulty comes from comparison of direct repairs vs. grafts, comparison of direct repairs vs. grafts, IAN and lingual nerve “lumping”, IAN and lingual nerve “lumping”, inconsistent indications and lack of inconsistent indications and lack of randomized controlled trials for outcomesrandomized controlled trials for outcomes
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Questions for treatmentQuestions for treatment
Frame the dilemma as an evidence-based Frame the dilemma as an evidence-based questionquestion
Retrieve applicable, valid and current Retrieve applicable, valid and current evidence to answer the questionevidence to answer the question
Appraise the evidence for applicability and Appraise the evidence for applicability and validity. What are the results?validity. What are the results?
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Using Ultrasound to Using Ultrasound to Visualize the Visualize the Lingual NerveLingual Nerve
Presented by James OlsenPresented by James OlsenHSDM 2006HSDM 2006
January 20, 2006January 20, 2006
http://i.cnn.net/cnn/2003/HEALTH/08/27/ultra.stethoscope/story.portable.ultrasound.jpg
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Mandibular Nerve BranchesMandibular Nerve Branches
A. AuriculotemporalB. LingualC. Inferior AlveolarD. N. to the MylohyoidE. MentalF. Buccal
http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/h_n/cn/cn1/images/cnb3.jpg
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Lingual Nerve AnatomyLingual Nerve Anatomy
The lingual nerve crosses the submandibular duct twice in the paralingual space.
http://www.sciential.net/images/Clemente2f.jpg
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Lingual Nerve AnatomyLingual Nerve Anatomy
Pogrel MA, Renaut A, Schmidt B, Ammar A. The relationship of the lingual nerve to the mandibular third molar region: an anatomic study. J Oral Maxillofacial Surgery, 1995, pp. 1178-81.
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Lingual Nerve InjuryLingual Nerve Injury
Loss of taste from anterior 2/3 of tongue ipsilateral to the lesion (special sensory component of CN VII)
Loss of general sensation from the tongue (general sensory component of CN V3).
http://info.med.yale.edu/caim/cnerves/cn7/cn7_graphics/fig7_25.gif
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Treatment of Lingual Nerve Treatment of Lingual Nerve InjuriesInjuries
Robinson PP, Alison RL, Julian MY, Smith KG. Current management of damage to the inferior alveolar and lingual nerves as a result of removal of third molars. British Journal of Oral and Maxillofacial Surgery, 2004; 42, 285-292
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Case ReportCase Report
*Images courtesy of Dr. Donoff
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Case ReportCase Report
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Imaging of Lingual Nerve InjuriesImaging of Lingual Nerve Injuries
CT
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Imaging of Lingual Nerve InjuriesImaging of Lingual Nerve Injuries
Miloro M, Halkias LE, Slone HW, Chakeres DW. Assessment of the Linual Nerve in the Third Molar Region Using Magnetic Resonance Imaging. J Oral Maxillofacial Surgery, 1997; 55:134-137.
MRI MRI
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Using Ultrasound to Using Ultrasound to Visualize the Lingual NerveVisualize the Lingual Nerve
http://www.bbc.co.uk/health/images/300/ultrasound.jpg
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UltrasonographyUltrasonography
Altinok T, Baysal O, Karakas HM, Sigirci A, Alkan A, Kayhan A, Yologlu S. Ultrasonographic assessment of mild and moderate idiopathic carpal tunnel symdrome. Clinical Radiology, 2004 Oct; 59(10): 916-25
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UltrasonographyUltrasonography
De Kool BS, Van Neck JW, Blok JH, Walbeehm ET, Hekking IV, Gerhard H. Ultrasound imaging of the rabbit peroneal nerve. Journal of the Peripheral Nervous System, 10 (4), 369-374.
PN, peroneal nerve; TN, tibial nerve; BF, biceps femoris muscle; SM, semimembranosus muscle; F, femur
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UltrasoundUltrasound
A pulse is generated and transmitted from the A pulse is generated and transmitted from the transducertransducer
– Frequency - number of repetitions per second (Hertz)Frequency - number of repetitions per second (Hertz)– Wavelength - distance between excitations (0.1 – 1.5 mm)Wavelength - distance between excitations (0.1 – 1.5 mm)
High frequency + short wavelength = Better resolutionHigh frequency + short wavelength = Better resolution– Amplitude - measured in decibelsAmplitude - measured in decibels– Period - time necessary for one cycle to occurPeriod - time necessary for one cycle to occur
(piezoelectric crystals)
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StudyStudy
Sonosite 180 Plus HST transducer (25mm, 10-5 MHz).
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StudyStudy
Yorkshire cadaverpig head
OMFSEndoscopic Research Center
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StudyStudy
Surgery, Anesthesia, & Experimental Techniques in Swineby M. Michael Swindle, DVM
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StudyStudy
Yorkshire cadaverpig head
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StudyStudy
Yorkshire cadaverpig head
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StudyStudy
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StudyStudy
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StudyStudy
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Table 1: Summary Diagnostic Outcomes for Three Evaluators
PigPig KeyKeyEvaluator #1Evaluator #1(Radiologist)(Radiologist)
Evaluator #2Evaluator #2(Senior Surgeon)(Senior Surgeon)
Evaluator #3Evaluator #3(Surgical Fellow)(Surgical Fellow)
11RightRight
Partial Partial TransectionTransection
IntactIntact IntactIntact Partial TransectionPartial Transection
LeftLeft Nerve IntactNerve Intact Full TransectionFull Transection IntactIntact Full TransectionFull Transection
22RightRight Partial Partial
TransectionTransectionPartial TransectionPartial Transection IntactIntact Full TransectionFull Transection
LeftLeft Full TransectionFull Transection Full TransectionFull Transection Full TransectionFull Transection IntactIntact
33RightRight Nerve IntactNerve Intact IntactIntact IntactIntact IntactIntact
LeftLeftPartial Partial
TransectionTransection Partial TransectionPartial Transection Partial TransectionPartial Transection Partial TransectionPartial Transection
44RightRight Full TransectionFull Transection Full TransectionFull Transection Partial TransectionPartial Transection Full TransectionFull Transection
LeftLeft Nerve IntactNerve Intact IntactIntact IntactIntact Partial TransectionPartial Transection
55 RightRight Full TransectionFull Transection Partial TransectionPartial Transection Full TransectionFull Transection Full TransectionFull Transection
Number of Correct Number of Correct Diagnoses (%)Diagnoses (%)
6 (66.7%)6 (66.7%) 6 (66.7%)6 (66.7%) 5 (55.6%)5 (55.6%)Average 17 / 27 (63%)
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ResultsResults
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ResultsResults
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Table 2: Average distance of lingual nerve from alveolus as measured with ultrasound
PigPigAve. distance from alveolus (mm)Ave. distance from alveolus (mm)
11RightRight 0.00.0
LeftLeft 1.8671.867
22RightRight 2.7562.756
LeftLeft 0.5330.533
33RightRight 0.00.0
LeftLeft 1.9561.956
44RightRight 0.9780.978
LeftLeft 0.3560.356
55 RightRight 0.7110.711
AverageAverage 1.021.02
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ResultsResults
Yorkshire cadaverpig head
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Case ReportCase Report
*Images courtesy of Dr. Donoff
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DiscussionDiscussion
– It is in fact possible to see the lingual nerve with It is in fact possible to see the lingual nerve with ultrasoundultrasound
– The result is near statistically significance – it is very The result is near statistically significance – it is very likely that a larger sample size is needed to detect likely that a larger sample size is needed to detect
the the difference as power may establish statistical difference as power may establish statistical significance for a relatively small effect size.significance for a relatively small effect size.
– The pig nerve is closer to the alveolus than it is in the The pig nerve is closer to the alveolus than it is in the human human
– Pig nerve is roughly ¼ the size of the human nervePig nerve is roughly ¼ the size of the human nerve
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ConclusionConclusion
– The results of this study show that The results of this study show that ultrasonography can be used to visualize the ultrasonography can be used to visualize the lingual nerve. Further studies and higher lingual nerve. Further studies and higher quality imaging are needed in order to quality imaging are needed in order to
determine the extent of involvement that determine the extent of involvement that ultrasound might have in both the prevention ultrasound might have in both the prevention and surgical planning process of lingual and surgical planning process of lingual
nerve nerve injuries.injuries.
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Susarla et al. JOMFS 65:1070, 2007
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Susarla et al.JOMFS 65:1070, 2007
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Susarla, et al. JOMFS 65:60, 2007
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Susarla, et al. JOMFS 65:60, 2007
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Hillerup and Stoltze. IJOMFS 36:1139, 2007
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Hillerup and Stoltze IJOMFS 36: 1139, 2007
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Hillerup and Stoltze IJOMFS 36:884, 2007
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Hillerup and Stoltze IJOMFS 36:884, 2007
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Caveats from ExperienceCaveats from Experience
Lingual nerve injuries usually not painfulLingual nerve injuries usually not painful Trigger in LN injuries with anesthesia positive Trigger in LN injuries with anesthesia positive
findingfinding IAN injuries often painfulIAN injuries often painful Operated IAN injuries often develop pain Operated IAN injuries often develop pain
syndromessyndromes Age is a very important factorAge is a very important factor Rare for anesthetic lingual nerve patients with Rare for anesthetic lingual nerve patients with
Tinel’s like sign to recoverTinel’s like sign to recover
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