Nerve Injuries / Orthodontic Courses by Indian Dental Academy

NERVE INJURIES AND
ITS REPAIR

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

INTRODUCTION

Nervous system performs the vital function
of COMMUNICATION for the body

PRIMARY ORGANS
The brain
spinal cord and
The nerves
MAIN TYPES OF CELLS
2 Types,-
Neuroglia: special connective tissue
cells of the nervous system
Neurons: these are the (unit) nerve
cells

NEUROGLIA
Number: 900 billion
Types,-
Astrocytes
Oligodendroglia
Microglia
Schwann cells

ASTROCYTES
Astron = star; kytos = cell.
Star shaped
Most numerous type
Webs of Astrocytes form tight sheaths
around the brains capillaries.
The tight junction between the endothelial
cells that form brain capillary walls together
constitute the blood-brain barrier

MICROGLIA
Small, stationary cells
In inflamed or degenerating brain tissue
they enlarge, move about and carry on
phagocytosis
OLIGODENDROGLIA
Smaller cells and have fewer processes than
Astrocytes.
They either lie clustered around nerve cell
bodies or arranged in rows between nerve
fibers in the brain and cord.
Holds nerve fibers together
Produces fatty myelin sheath
over the fibers in the brain and
cord
SCHWANN CELLS
Not found in the brain and the cord
Found in the peripheral nerves of the body
They function to form the,-
Neurilemma
Myelin sheath
NEURONS
Number: 100 billion
These are the unit cells of the nervous
system
forms the basic unit of the nerve fiber

CLASSIFICATION

According to the direction in which they
conduct impulse:
Afferent, efferent and interneurons.
According to number of processes:
Multipolar, bipolar and unipolar
AFFERENT/SENSORY
NEURONS
Transmits nerve impulses to the spinal cord
or brain
EFFERENT/MOTOR NEURON
They transmit nerve impulses away from
the brain or spinal cord to or towards the
muscles or glands
INTERNEURONS
They lie entirely in the central nervous
system
They conduct impulses from the afferent
neurons toward efferent neurons
MULTIPOLAR NEURONS
Most of the neurons in the brain and spinal
cord are multipolar
They have only 1 axon but several
dendrites.

BIPOLAR NEURONS
Have one axon and one dendrite
Least type
found in, retina of eye, the spiral ganglion
of the inner ear and the olfactory pathway
UNIPOLAR NEURONS
Originate in the embryo as bipolar neurons
During course of development the 2
processes fuse for a short distance beyond
the cell body.then they separate into clearly
distinct axon and dendrite
Sensory neurons are mostly unipolar
STRUCTURE
Neurons consists of,
Cell body
Axon and
Dendrites
CELL BODY/SOMA/
PERIKARYON
Largest part of the nerve cell
In clusters cell bodies have gray colour
And are known as nuclei in brain and spinal
cord and ganglia elsewhere
It contains nucleus, cytoplasm and various
organelles found in other cells
.
Cytoplasm
A neurons cytoplasm extends through its cell
body and its processes.
A plasma membrane encloses the entire
neuron
structures dendrites, axons, neurofibrils,
nissl bodies, myelin sheath and neurilemma
are only found in the neurons
DENDRITES
Dendrites = tree in Greek
terminal branches of the Multipolar neurons
Distal ends of sensory neurons are called as
receptors
They conduct impulses to the cell body of
the neuron
AXON
single process extending from the cell body.
Vary in length and diameter
Length- max.a meter long; min.few mm
Diameter- max. 20microns; min. 1micron
Diameter directly proportional to velocity of
conduction
Conducts impulse away from cell body.

Axons terminate in many branched
filaments called telodendria and they
contain numerous vesicles and
mitochondria.
NEUROFIBRILS
These are very fine fibers extending through
dendrites, cell bodies and axons.
They consist of still thinner fibers
microtubules and microfilaments.
NISSL BODIES
Consists of layers of small pieces of the
endoplasmic reticulum with many
ribosomes lying between them.
They appear as large granules widely
scattered through the cytoplasm of the cell
body only.
.

specialized in protein synthesis.
needed for maintaining and
regenerating neuron processes and for
renewing chemicals involved in the
transmission of nerve impulses from
one neuron to the other.
THE MYELIN SHEATH
A segmented wrapping of fatty substance
around an axon called myelin.
One segment of myelin sheath extends
from one node of Ranvier to the next.
One Schwann cell forms one segment of the
myelin sheath around an axon located in a
nerve .
A loop of Schwann cells plasma membrane
pushes inwards towards the section of axon
adjacent to it and wraps itself in a jelly-roll
fashion around that section.
this inward movement of the loop plasma
membrane squeezes the rest of the cell in
the outer direction to form neurilemma.

The several rolled up layers of the Schwann
cells plasma membrane lying inside the
neurilemma constitute the myelin sheath.

Fibers that have myelin sheath are called
myelinated fibers and those that have only
thin layer of myelin are called unmyelinated
nerve fibers
A tract is a bundle of myelinated axons.
The high fat content of myelin gives it a
creamy white colour and make up the white
matter of the brain and spinal cord.
White matter found outside the brain and
cord consists of nerves
NEURILEMMA/
SHEATH OF SCHWANN
a delicate outer covering around the axon
located outside of the brain and cords in
nerves and plays an essential part in the
regeneration of cut and injured axons.
Axons in the brain and cord have no
neurilemma and hence don't regenerate.
but those in nerves do.
Etiology
Nerve injuries result from a variety of oral and
maxillofacial surgical procedures,such as,-
Third molar odontectomy
Management of facial trauma
Orthognathic surgery
Endosseous dental implant placement


Salivary duct and gland surgery
Treatment of benign and malignant lesions
of the head and neck
Preprosthetic surgery and
Endodontic and periradicular surgery

CLASSIFICATION OF
NERVE INJURY
SEDDONS CLASSIFICATION:(1943)
Neuropraxia
Axonotmesis
Neurotmesis

Neuropraxia:
Usually compression injury (mild)
Local conduction block & demyelination
Thick myelinated nerves mainly affected
Heals by repair of demyelination by
Schwann cells, takes hours to several days
Axonotmesis:
Usually after traction injury or severe
compression
Wallerian degeneration occurs
Endoneurial tubes are intact & good
sensory recovery but incomplete and takes
several months.
Limiting factor is the distance of
regeneration required.
Worse with proximal injuries
Deficit is severe paresthesia.

Neurotmesis:
Most severe, there is severance of the
nerve.
Sensory deficit is either anesthesia or
dysesthesia.
Intraosseous nerve injuries may exhibit
some degree of sensory recovery as the
canal acts as a guide.
SUNDERLAND
CLASSIFICATION
Classified in the year 1951
Accounts for the injuries between an
Axonotmesis and Neurotmesis
based on involvement of the perineurium
First degree injury:
Same as neuropraxia
Axonal conduction blockade as a result of
ischemia or mechanical demyelination.
Three types,
type 1, 2 and 3

Type1: result of manipulation(mild traction
or mild compression) seen in sagittal ramus
osteotomy, lingual nerve manipulation
during sialadenectomy.
Conduction block due to interruption of
segmental or epineurial blood vessels.
Recovery within hours(24 hrs)

First degree type 2
Results from moderate manipulation
Conduction block due to intrafascicular
edema from trauma to injure the
endoneurial capillaries
Recovery within a week with resolution of
edema

First degree type 3
Due to severe nerve manipulation
Segmental demyelination seen,response is
paresthesia.
Recovery is complete with in 1 to 2 months
Surgery not indicated in first degree unless
there is a foreign body irritant

Second degree injury
Second ,third and fourth degree injuries
overlap with Seddons axonotmesis
The axons are damaged and undergo
degeneration and regeneration, rest nerve
components remain intact
Generalized paresthesia with localized area
of anesthesia is present
Surgical intervention not reqd.

Third degree injury
The intrafascicular tissue components, the
axons and endoneurium are damaged
Recovery is fair to poor with some degree
of persistent paresthesia/synesthesia
Surgical intervention dictated by the
sensory disturbance,the recovery
pattern,presence of foreign body and
severity of injury
Fourth degree of injury
Fascicular disruption with damage to axons
endoneurium and perineurium
Neuropathic sensory impairment high due
to extensive internal fibrosis
Results in
anesthesia,dysesthesia,synesthesia and
severe paresthesia
Sensory recovery is poor
Requires surgical intervention
Fifth degree injury
Transection or rupture of the entire nerve
trunk
Results in loss of nerve conduction at level
of injury & in distal nerve segment
Recovery is poor
Better in intraosseous injury (if canal is
intact).
requires surgical adaptation & coaptation
Sixth degree injury
Added by Mackinnon & Dellon
Its a mixed combination of Sunderland's
five degrees of injury
Within the same nerve trunk some fascicles
may exhibit normal function & others with
varying degrees of nerve injury
Presents greatest challenge to the surgeon
Physiologic Conduction Block
Type A conduction block
Is due to intraneural circulatory arrest or
metabolic{ionic}block
No nerve fiber pathology
Immediately reversible
Improves with restoration of circulation to
nerve trunk
Type B conduction block
Is due to intraneural edema resulting in
increased endoneurial fluid pressure or
metabolic block
Little or no nerve fiber pathology
Complete recovery within days to week
Improves with decrease in edema and
increased venous drainage
Symptomatic Classification
Based upon subjective complaints of
numbness
Broadly classified into:
Anesthesia
Paresthesia
Dysesthesia

Anesthesia
Complete loss of any stimulus
detection,stimulus localization or stimulus
interpretation or perception
Associated with severe injury
recovery slow & unpredictable
Surgical intervention necessary

Paresthesia

Is an alteration in sensibility in which there
is abnormal stimulus detection &stimulus
perception that may be perceived as
unpleasant but is not painful.

Stimulus{touch & pressure / pain} detection
may be normal,increased {hyperesthesia /
hyperalgesia}or decreased {hypoesthesia
/hypoalgesia} & may affect either
mechanoreception or nociception

These abnormalities are the result of
conduction disturbances, ischemia
&alterations in protein transport along the
axon to the peripheral receptor & not
necessarily from disruptions of the axons
Difficulty in quickly & accurately localizing
the point of stimulus application is called
synesthesis

It is probably the result of misdirection of
axons during the process of regeneration
and is common finding following
neurorrhaphy
Distal nerve atrophy is not a concern with
paresthesias therefore there is no urgency
for surgical exploration & repair

Dysesthesia
There is abnormal stimulus detection &
stimulus perception that may be perceived
as unpleasant and painful
It is paresthesia with pain which may be
spontaneous or triggered

Types of Dysesthesia

Allodynia,Hyperpathia(to pressure)
These types are associated with
neuromas,entrapment and sympathetically
maintained pain and require surgical
intervention.

Anatomic classification
Intraosseous nerve injury
Soft tissue nerve injury
Histopathologic classification:
Neuroma
fibrosis
Pathophysiologic classification:
Compression
Compartment syndrome
Stretch injury
Transection, laceration, rupture and avulsion
Chemical injury
Nerve injection injury
Autonomically maintained pain
Central neuropathy

Clinical Neurosensory Testing
McGill pain questionnaire
Visual analog scale
Nonsurgical treatment

Treatment algorithms

Surgical treatment
Exposure
External neurolysis
Internal neurolysis
Nerve stump preparation
Approximation
Coaptation

External neurolysis

Internal neurolysis
It refers to surgical manipulation within the
epineurium to prepare the nerve for repair
Types of internal neurolysis
Epifascicular epineurotomy
Epifascicular epineurectomy
Interfascicular epineurectomy
Neurorrhaphy


Nerve graft

Entubulation techniques

Direct nerve repair

Cross face nerve grafting
(faciofacial anastomoses)

Nerve crossovers

Regional muscle transposition

Free muscle grafts

Nerve-muscle pedicle technique

Microneurovascular Muscle
Transfers


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