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An instance of permanent neuropathy that affected the mandibular nerve after a vaso-occlusive crisis in a patient with homozygous sickle cell disease and G6PD deficiency. A local factor of molar periapical inflammation may have provoked this phenomenon.
Cell bodies of primary afferent neurons comprizing individual peripheral branches of the rat mandibular nerve were labeled by retrograde transport of HRP and their sizes were measured. Approximately 60% of cell bodies of primary neurons innervating the intra and perioral structures through the inferior alveolar, lingual, mental, and buccal nerves were in the range between 300 and 600 micron 2 in cross-sectional area: mean +/- SD 509 +/- 243 micron 2, 420 +/- 181 micron 2, 469 +/- 200 micron 2, and 444 +/- 186 micron 2, respectively. Sixty-five percent of cell bodies of primary neurons innervating the periphery of the face through the cutaneous branch of the mylohyoid and auriculotemporal nerves were smaller than 300 micron 2 in cross-sectional area: 285 +/- 170 micron 2 and 286 +/- 172 micron 2, respectively. The data suggest that the intraoral/perioral region is different from the skin in the peripheral region of the face in terms of the mechanism by which sensory information is transmitted to the central nervous system. This difference may explain some of the formerly enigmatic phenomena such as the differential effects of spinal trigeminal tractotomy.
Failure to achieve complete mandibular anesthesia is a problem that often occurs. The explanations include faulty anesthetic solutions, faulty technique, and anatomic or physiologic variations. Bifurcation of the mandibular nerve, rarely mentioned in the literature, may be a cause of inadequate anesthesia in a small percentage of cases.
A new method for the block anaesthesia of the oral branches of the mandibular nerve is described. Only one penetration of the oral mucosa is made in this injection at a site which is relatively painless and which results in a more rapid onset of anaesthesia. This method is also of value when trismus or ankylsis is present and is free of common complications.
In a group of 44 patients, fundus photographs were taken before and after mandibular nerve anesthesia and examined by densitometry. These patients were divided into subgroups receiving 4 cm3 of Xylocitin 2% alone or in combination with 0.005% norepinephrine, or 0.00125 or 0.002% epinephrine. In the presence of epinephrine, the retinal arterioles reacted with a temporary age-dependent narrowing. A placebo group received normal saline or had just the needle inserted. With one interesting exception, the reactions were minimal. The cause of this reaction is a multifactorial one. In the first period, vagovagal reflexes are important; in the later phase, processes comparable to autoregulation play the main role.
OBJECTIVES: The objective of this work is studying wariable anatomy formations at the posterior border of the pterygoid process lateral plate of the sphenoid hobe (lig. et foramen pterygospinale, lig. et foramen crotaphitico-buccinatorium), and its statistical processing considering sex, age and sides of studied sculls. MATERIAL AND METHODS: At 305 sculls of mature persons of both sexes (167 males and 138 females) we studied incompletely ossificated lig. pterygospinale, opening of the same name which has become by its full ossification, incompletely ossificated lig. crotaphitico-buccinatorium and opening made by it's complete ossification, and position of this structures in relation to foramen ovale. RESULTS: Incompletely ossificated lig. pterygospinale was found at 12 sculls on both sides or 3.93% (8 male's and 4 female's sculls). One-sidedly, on the right one, incompletely ossificated lig. pterygospinale was found at 14 sculls (4.59%), and on the left side at 19 sculls (6.22%). Incompletely ossificated lig. pterygospinale, present on both sides of sculls, was in the case of persons older than 50 (9 sculls or 75%). Pterygospinous opening which has become by complete ossification of lig. pterygospinale was found on both sides at 4 sculls (1.31%), two of them were male's and two of them female's sculls. In alll four cases persons were older than 40. Pterygospinous opening found on the left side was present at only 3 sculls (0.98%) and on the right side at 4 sculls (1.31%). Pterygospinous opening was present one-sidedly, every time, in the case of male's sculls. Incompletely ossificated lig. crotaphitico-buccinatorium, meaning incomplete opening, was found at 17 sculls on both sides (5.57%). 10 of them were male persons' sculls, and 7 of them females'. On the right side, incompletely ossificated lig. crotaphitico-buccinatorium was found at 11 sculls (3.60%)--6 male's and 5 female's, and on the left side at 16 sculls (5.24%). Foramen crotaphitico-buccinatorium was found on both sides only at 12 sculls (0.97%)--one male's and one female's. Foramen crotaphitico-buccinatorium was found on the left side at 8 sculls (3.90%) and, on the right side, this opening was found at 3 sculls (0.98%). Incompletely of completely ossificated lig. pterygospinale, located laterally from foramen ovale, was found at 5 sculls (5 male's and 1 female's) or 1.63%, and in the other case, incopletely or completely ossificated lig. crotaphitico-buccinatorium laterally from foramen ovale was found at 7 sculls (5 male's and 2 female's) or 2.29%. CONCLUSION: While applying conductive anaesthesia on mandibular nerve by lateral subzygomatic route, variable ossificated formations at lateral plate's posterior border of pterygoid process should be kept in mind. It is possible that a needle, at a depth of 35 mm, comes across incompletely or completely ossificated lig. pterygospinale et crotaphitico-bucciantorium. Based on ours anatomy research we concluded that these formations are more oftenly present on males aged over 50, and that one-sided presence is more often on the left side. Ossificated formations which were the object of our research are not an obstacle to high-quality applying of conductive anaesthesia on trigeminale ganglion et mandibular nerve each time when they exist, but only when they are located laterally from foramen ovale, what appeared at 12 sculls (3.93%) in our case.
OBJECTIVE: To present our experience of regional anaesthesia with blocks of the foramen rotundum and the oval foramen. DESIGN: Open study. SETTING: University Hospital, Beograd, Yugoslavia. SUBJECTS: 107 patients who underwent 58 maxillary and 49 mandibular nerve blocks. INTERVENTIONS: Injection of 2% lignocaine with adrenaline 1/80,000 with an 18 G venflon or 20 G spinal needle. MAIN OUTCOME MEASURES: Quality of anaesthesia and morbidity. RESULTS: 49 of the 58 maxillary (84%) and 45 of the 49 mandibular (92%) nerve blocks were successful (no sensitivity to pinprick in the distribution of the injected nerve and a painless operation). There were 17 complications (26%), 8 in the maxillary and 9 in the mandibular group. All complications were minor and transient, and 6 could be attributed to anhydrous glycerol rather than the injection technique itself. CONCLUSION: Blocks of the foramen rotundum and the oval foramen achieve good regional anaesthesia in the maxillofacial region.
Epithelial islands in association with nerve fibers in the jaw bones have been reported previously. We describe two such cases and present evidence that the epithelial structures as observed in this study are odontogenic rests and not neuroepithelial organs. Regardless of origin, it should be recognized that these epithelial islands do not represent neural invasion by carcinoma.
The capacity of 4 patients who had previously experienced trauma to their mandibular nerves to distinguish opposing directions of tactile motion over the distribution of the mental nerve was compared to that of 8 neurologically normal adults. Brushing stimuli were delivered to the perioral region and were precisely controlled for their velocity, the length of skin traversed, the width of skin contacted, and the orientation and direction of motion. A temporal, 2-alternative, forced choice method was used to obtain estimates of directional sensitivity, d'. It was discovered that impairment in cutaneous directional sensitivity could be readily detected within areas of hypaesthesia. Although directional sensitivity was found to increase linearly with the length of skin traversed for both the patients and the neurologically normal adults, the slope and the x-intercept of the linear relationship differed between the two groups. The difference in the slope suggests that direction discrimination within the hypaesthetic areas is relatively insensitive to changes in the length of skin traversed. The difference in the x-intercept suggests that a greater length of skin must be traversed before any information about direction is made available at the hypaesthetic sites. The dependency of the capacity of neurologically normal and impaired individuals to process information about direction of tactile motion on the length of skin traversed and the velocity of stimulation suggests that a high degree of stimulus control is required for the detection and quantification of subtle neurosensory deficits.
In patients who show their lower teeth during smiling and facial animation, paralysis of the marginal mandibular nerve (MMN) causes a noticeable asymmetry of the lower lip due to the absence of depressor function. This paper presents a balancing technique for this lower lip asymmetry that involves resection of the depressor labii inferioris (DLI) on the nonparalysed side. The anatomy of the muscle, the operative technique, and the effectiveness of the procedure are outlined. A retrospective chart review was performed for 42 adult patients who were treated for MMN palsy with a DLI resection. Seven cases had only the MMN involved, and 35 cases had unilateral facial nerve paralysis. Thirty-six of these patients were available for a follow-up telephone survey. Of the 42 primary DLI resections performed, 36 cases had successful outcomes. Of the six patients who failed to achieve the expected results, five patients had repeat DLI resection and three of these achieved the desired result; the other two patients required a third resection. One patient continued to have DLI action with smiling and subsequently had a Botox injection into the DLI with good results. Of the 36 survey respondents, 21 patients felt their lower lip was asymmetrical at rest prior to DLI resection and 18 of these patients were improved by the procedure (P = 0.0001). Twenty-nine of the 36 patients reported that their lower lip was more symmetrical when they smiled following the DLI resection (P < 0.0001). The bilateral lack of movement in the lower lip when expressing emotions, such as anger and sorrow, was not as important to the patient as the lack of symmetry when expressing these emotions. Patients' speech either improved or showed no change, the amount patients bit their lower lip significantly improved (P = 007) whereas oral continence showed no significant changes (P = 0.147) following the DLI resection. DLI resection is a simple and effective procedure for the treatment of MMN palsy. The results are permanent and predictable. Lower lip symmetry is produced both at rest and with facial animation, without causing a functional deficit. The expected results of surgery can be trialed by local anaesthetic or botulinum toxin to block the activity of the DLI.
Sensory complaints in the area of the mandible and mouth often escape notice or remain undiagnosed. Using electromyographic recording of the trigeminal reflexes and motor responses, we sought trigeminal dysfunction in 50 patients with peripheral neuropathy, and tried to gain pathophysiological information on the mechanisms provoking trigeminal damage. Trigeminal reflex recordings (early and late blink reflex after supraorbital stimulation, early and late masseter inhibitory reflex after mental stimulation, and jaw jerk) disclosed abnormalities caused by sensory trigeminal neuropathy in 8 out of 15 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 out of 23 patients with severe diabetic polyneuropathy, and in none of 12 patients with mild diabetic polyneuropathy. Six patients had abnormal motor responses in facial or masseter muscles. The response affected most frequently was the masseter early inhibitory reflex (also called first silent period, SP1) after mental nerve stimulation, its latency being strongly delayed. We found these long delays not only in patients with CIDP, but also in diabetic patients with severe polyneuropathy. We conclude that peripheral polyneuropathies often cause subclinical damage to the trigeminal nerve, especially to its mandibular branch. We believe that the nerve fibers running along the alveolar-mandibular pathway are more exposed to damage because of their cramped anatomical route in the mandibular canal and below the internal pterygoid muscle and fascia.
Total sensory loss, ptosis, ocular muscle palsy and pupil dilatation were noted after alcohol injection into mandibular nerve for idiopathic trigeminal neuralgia (in the right 2. and 3. division). The diagnosis was made that the injected alcohol induced the Gasserian palsy and oculomotor palsy. The oculomotor palsy was fully recovered except slight pupil dilatation after four months. The mechanism and prophylaxis of these complications are discussed.
The aim of this study was to improve the injection technique when blocking the mandibular nerve at the oval foramen by using consistent landmarks. The lower lateral orbital angle (LLOA) and the junction of the external acoustic canal and the mastoid process (AM) proved to be reliable landmarks. Distances between landmarks for the localization of the puncture point (PP), cranial indices as well as the angle of the injection needle to the sagittal plane were calculated on 22 human dried skulls. The PP was found to lie exactly in the middle between the LLOA and AM. The angle of the injection needle to the sagittal plane was 71.86 degrees. No correlation was found between the cranial index and the angulation of the needle or the distances for the localization of the PP. From this study a modified puncture technique was developed.
Grafting is one treatment option for patients who have insufficient bone for implant placement. However, repositioning the neurovascular bundle also can allow for placement of endosseous implants. This case illustrates bilateral repositioning of the mandibular nerves and subsequent implant placement.
Pseudotumor is a term used to describe a space occupying inflammatory lesion which mimics a true neoplastic process in its clinical presentation. In this paper, we report a pseudotumor of the pterygomaxillary space that presented with anesthesia and paralysis of the mandibular nerve. The importance of this case is to call attention to pseudotumors as a clinical entity and to document a case of an extraordinarily aggressive variant that required a surgical approach usually reserved for malignant tumors.
Laser Doppler flowmetry (LDF) was used to study the effect of mandibular nerve block, using 3% mepivacain, on heat- or cold-induced changes in pulpal blood flow (PBF) evoked by application of cold or heat to the lingual surfaces of teeth 33 and 43 in nine young subjects. PBF on average showed a 7% increase in response to heat (48 degrees C) and a 20% decrease when exposed to cold (3 degrees C). Neither response was affected by mandibular block. From this we concluded that the effects on PBF of the presently applied heating and cooling of the tooth were solely due to direct thermal influences on the blood vessels, without involvement of vasomotor or sensory nerves.
A 68-yr-old hypertensive patient with ischemic heart disease and intractable atrial fibrillation with stable hemodynamics and poor chest compliance underwent pleomorphic adenoma of the parotid gland using regional anesthesia with continuous propofol sedation. Continuous maxillary and mandibular nerve blocks were performed and excision was performed with complete intraoperative and postoperative pain relief without compromising the patient's hemodynamic variables.
We observed a case of linear lichen planus extending from the right cheek to the jaw, which was accompanied by itching and an unusual sensation in the mouth. The eruption was located along the mandible and aligned with the mandibular nerve. The right molars of the patient contained metal compounds and these were considered to be the cause of his disease. Patch testing with various dental metals showed positive reactions to palladium and platinum. A biopsy specimen showed a lichenoid reaction in the lesional tissue, and dermal contact dermatitis was noted at the palladium patch test site. His dentist reported that palladium-silver-gold or nickel-chrome alloys without platinum had been used in the crown and bridge of his molars. After removal of the dental alloys, the skin eruption resolved with some residual hyperpigmentation. In addition, the peculiar mouth sensation disappeared dramatically within 2 months.