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V. A. Manon et al.
Introduction
Continuous advances in surgical techniques and immunotherapies are anticipated to
improve survival rates of patients with head and neck cancer, placing even greater
emphasis on maxillofacial reconstruction by surgeons. While much of this attention
has been directed toward the restoration of muscular and bony structures, increased
patient longevity has directed focus toward the reconstruction of resected nerves following resection of pathology. The purpose of this review was to discuss the impact
of inferior alveolar nerve (IAN) and/or lingual nerve (LN) resection on quality of life
and examine the numerous reconstructive options now available to practitioners.
Methods
A literature review was conducted to determine the qualitative and quantitative effects
of IAN and/or LN resection on quality of life (QoL), using scales such as the Medical
Research Council Scale (MRCS) and/or the Oral Health Impact Questionnaire (OHIP).
We also searched for data regarding the relationship of time to nerve reconstruction
and improvement in functional sensory recovery and overall QoL.In accord with the
policy of the institutional review board of the University of Texas Health Sciences
Center at Houston (UTHealth), institutional review board approved of this study.
Results
Persistent paresthesia and/or anesthesia of the IAN or LN results in signicantly
reduced quality of life with psychosocial and physical implications. Patients report
interferences in their ability to socialize (i.e., retaining food particles on the face or
drooling) and difculties with employment. Other psychological implications
include increased social anxiety and symptoms of clinical depression. When
addressed within 9months of injury or resection, reconstruction of the inferior alveolar and/or lingual nerves via direct neurorrhaphy, autografts, or processed allogeneic grafts has successfully demonstrated marked improvements in patients’
functional sensory recovery and overall quality of life.
Conclusion
The results of this review indicate that timely reconstruction of the inferior alveolar
and/or lingual nerves can lead to signicant improvements in functional sensory
recovery and patient quality of life. When reviewing options for reconstruction of
maxillomandibular and oral structures, consideration of nerve reconstruction should
also be prioritized.
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Background
The inferior alveolar (IAN) and lingual (LN) nerves are branches of the mandibular
nerve, the third branch of the trigeminal nerve (cranial nerve V). When functioning
normally, the IAN provides sensation to the lower teeth and lip, while the LN provides general sensory innervation to the anterior two-thirds of the tongue. Upon
exiting the mandible at the mental foramen, the IAN continues as the mental nerve
providing sensation to the front of the chin and lower lip. These functions facilitate
daily activities such as chewing, smiling, and tasting, which play an important role
in social interactions. Damage to the IAN or LN during surgery can result in anesthesia or paresthesia of the affected structures, therefore interfering with daily activities and the patient’s quality of life. Injury of these structures occurs most commonly
during lower third molar extractions, but certain procedures, such as mandibular
resections for benign or malignant pathology, may also require the resection of
these nerves. While reconstruction of bone and soft tissue defects has been extensively studied and is a common procedure for most oral surgeons, reconstruction of
the nerves is less common and not always considered by surgeons, which can leave
patients with persistent functional sensory decits.
Various techniques are available to the surgeon for reconstruct of the IAN and/or
LN; if possible, nerve reconstruction should be implemented during the primary
reconstruction, particularly after mandibular resections for benign and malignant
head and neck pathology. As advances are made in surgery, chemoradiation, and
now immunotherapy, patient survival rates for head and neck cancer have increased
from 53% in the 1970s to 66% in 2010 [1]. Surgical management of benign and
malignant pathology of the maxillomandibular region includes resection of the
affected structures, often including the IAN and LNs. Improvements in survival
rates have motivated surgeons and their patients to pursue additional surgeries to
reconstruct the residual defects. This should include reconstruction of the resected
neural structures to improve the surviving patients’ quality of life. While direct neurorrhaphy can be used for nerve transections where nerve stumps are in close proximity, this requires approximation of the free nerve stumps without tension and is
not feasible for larger spanning defects. Autogenous grafts, commonly requiring
harvest of the sural nerve, may be successfully used in younger patients but can
result in donor site morbidity, including the additional surgical site and sensory decits in the distribution of the harvested nerve. Decellularized allogenic nerve grafts,
such as the AxoGen AVANCE graft, can be used to successfully reconstruct neural
defects over distances of 5–70mm without tension, donor site morbidity, or immunosuppression. Nerve reconstruction techniques have demonstrated greater functional sensory recovery (FSR) with early intervention as compared to delayed or no
intervention. Patients that do not receive early intervention often report persistent
neurosensory disturbances, affecting their overall quality of life [2–6]. While early
intervention is advocated over delayed intervention, Robinson etal. found that there
was no correlation in outcome measures and timing of repair for lingual nerve injuries [7]. Instead they found that early or delayed intervention did not reduce the
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Table 18.1 Medical Research Council Scale (MRCS) for neurosensory recovery
Score Parameter FSR
S0 No recovery No
S1 Recovery of deep cutaneous pain No
S1+ Recovery of some supercial pain No
S2 Recovery of some supercial pain and tactile
sensation
S2+ S2 with over-response No
S3 S2+ without over-response and 2-PD >15mm Yes, clinical recovery
S3+ S3, plus 2-PD=7–15mm Yes
S4 S3+, plus 2-PD=2–6mm Yes, complete recovery
No
V. A. Manon et al.
number of patients with dysesthesia, but reduced the quality of their symptoms.
Patients that do not receive surgical intervention often report persistent neurosensory disturbances, affecting their overall quality of life.
Patients with residual decits of the IAN and/or LN consistently report higher
levels of dissatisfaction and poorer quality of life. Objective measures of functional
sensory recovery include neurosensory testing instruments and survey. The Medical
Research Council Scale (MRCS) is commonly used, although this measure does not
assess the patient’s self-perceptions of quality of life or impact on daily activities.
The MRCS uses neurosensory tests, such as two-point discrimination, brushstroke
directional sensation, contact detection, and pain and temperature nociception, and
scores the recovery on a scale from S0 to S4 (Table18.1) [8, 9]. While these measures are crucial for the evaluation, documented measurements of the patients’ subjective experiences are less likely to be collected and discussed. Other methods can
be used to assess subjective sensory recovery, such as surveys or the visual analogue
scale (scale, 0–10, with 0 = completely anesthetic and 10 = normal sensation).
Various surveys have been designed and can be used to collect this information; the
Oral Health Impact Questionnaire (OHIP) and Short Form Health Survey (SF-36)
are widely used today [10, 11]. The OHIP, originally developed by Slade in 1977, is
a 49-question survey used to evaluate the patient’s perceptions of their functional
disability, physical pain, physical disability, psychological disability, social disability, psychological discomfort, and handicap. The OHIP-14 is an abbreviated,
14-question version of the OHIP.The SF-36 can be used to measure health-related
quality of life using eight subcategories of physical and mental components. The
physical component score (PCS) includes physical functioning, role-physical,
bodily pain, and general health. The mental component score (MCS) includes
patient perceptions of vitality, social functioning, role-emotional, and mental health.
These scores quantify the patients’ self-perceptions of physical and mental healthrelated quality of life [12]. Patients with persistent neurosensory disturbances evaluated using the OHIP and/or SF-36 after IAN and/or LN damage are found to report
consistently higher levels of dissatisfaction in each category. These studies demonstrate that these patients have poorer quality of life as compared to those that do not
have these neurosensory disturbances [10–12].
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The purpose of this paper is to discuss the decreased quality of life observed in
patients with IAN and LN neurosensory disturbances and encourage practitioners to
consider neural reconstruction in the effort to improve the lives of their patients.
Advances in the management of head and neck cancer have increased the survival
rates of patients requiring major resections of the mandible and associated neural
structures, and this improvement has led to the need for reconstruction of the
patient’s maxillomandibular defects. Failure to reconstruct the patient’s IAN and/or
LN leads to persistent neurosensory disturbances, reducing the patient’s quality of
life. When possible, immediate reconstruction of the nerves should be seriously
considered during surgical planning. The surgeon should be aware of the psychosocial impact nerve decits can have and should discuss this, as well as treatment
options, with the patient.
327
Review ofLiterature
How Does This Problem Impact andAffect theAficted
Population andHow Can It BeMeasured?
Patients with persistent neurosensory disturbances after IAN and/or LN damage
consistently report reduced quality of life related to their injuries. When evaluated
using the OHIP-14 and/or SF-36, patients consistently report more functional/physical limitations and psychological discomfort and disabilities as compared to those
that did not suffer the same injury [10–12]. Reported functional/physical limitations
include difculty eating, speech deterioration, inability to detect food on the lip
when eating, and unawareness of drooling [12, 13]. Negative impacts of these physical limitations have social implications including the patients’ ability to socialize
with others, their ability to enjoy their food, and their difculties with employment
[12, 14]. The psychosocial implications of these difculties can impact the patients’
self-perceptions, leading to increased social anxiety, difculty managing emotions
of anger and irritability, and even clinical depression [10, 14]. While neurosensory
recovery is an important parameter to record when these injuries occur, understanding the patients’ physical and psychological disabilities that resulted from this
injury is equally as important to understand and document.
The surgeon’s ability to elicit and discuss the aforementioned problems can help
them properly inform the patient of complications associated with IAN and/or LN
injury prior to surgery and to manage the aficted patient postoperatively. Patel
etal. conducted interviews with ve aficted patients, nding many were dissatised with the initial consent process, their injury, and postoperative management
[12]. Many questioned the informed consent process and stated they felt they were
not properly informed of the quality of life implications associated with neural damage. They expressed a desire for more information preoperatively and on the recovery prognosis. This indicates a need for a more comprehensive, preoperative
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discussion regarding the impact on quality of life that neurosensory decits can
cause. Many also expressed signicant frustration and anger associated with the
injury, indicating that they felt they were not appropriately managed initially after
the injury. Patel et al. found that the average time of referral to a specialist was
7months postoperatively (range 3weeks to 18months). Patients indicated that they
would like disclosure of their neurosensory prognosis and prompt management.
Given the physical and psychosocial implications of these injuries, there is a need to
improve postoperative management, including early referral to a specialist, surgical
intervention, and management of patient expectations [12, 15, 16]. In accord with
the policy of the institutional review board of the University of Texas Health
Sciences Center at Houston (UTHealth), institutional review board approved
this study.
V. A. Manon et al.
Available Surgical Interventions
Surgical intervention of neural injuries is critical for improvement of functional
sensory recovery and improvement of quality of life. Once the surgeon identies a
nerve injury or knows that treatment will require transection of neural structures,
prompt initial management is necessary for clinical success and patient satisfaction
[2–7]. Indications for trigeminal nerve repair include observed nerve transection,
lack of clinical improvement of paresthesia for >3months, development of neuropathy due to nerve entrapment or neuroma formation, presence of a foreign body,
worsening paresthesia or dysesthesia, and hypoesthesia affecting patient’s quality
of life [3]. Techniques for neural repair or reconstruction include direct neurorrhaphy, autogenous nerve grafts, vascularized free aps, and decellularized allogenic
nerve grafts.
Direct neurorrhaphy is the direct repair of the proximal and distal nerve stumps.
The most commonly used method for direct nerve repair of the IAN or LN is the
epineural suture technique. Successful surgical outcomes, dened as return of useful sensory function, are best achieved with timely repair (within 9months from the
time of injury) and tension-free approximation of the nerve ends. In a retrospective
study of 222 lingual nerve repairs, Bagheri et al. found that 90.5% of patients
achieved useful sensory recovery or complete return of sensation with use of this
technique [2]. Patients that sought surgical intervention after 9months were signicantly less likely to achieve any meaningful sensory recovery. The study also found
that age and preoperative symptoms were important determinants of surgical success. For every year above the age of 45, the chances of obtaining functional sensory
recovery decreased 5.5%; preoperative numbness, as compared to preoperative
pain, was a negative indicator for return of sensation.
Autogenous nerve grafting, considered the gold standard for peripheral nerve
grafting, allows tension-free approximation when larger defects are present [17,
18]. The surgeon must consider the following factors when determining the choice
of a donor nerve graft: accessibility, length required, diameter of donor nerve
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compared to host nerve, patient reference, and fascicular number and pattern. The
two most commonly used autogenous nerve grafts are the sural and great auricular
nerves (GAN). There is some debate as to the appropriate length for the use of certain nerve grafts. The great auricular nerve in the upper lateral neck has been the
most frequently harvested for nerve defects of less than 3cm, while the sural nerve
in the lower extremity is more suitable for longer nerve defects [19]. Wolford recommends that the GAN should only be used to reconstruct defects up to 1.5cm in
length and that the sural nerve should be used for defects up to 2.5cm [17, 19].
Although the graft can successfully be used to create a tension-free nerve repair, it
can be difcult to achieve ideal donor to recipient match and is associated with
donor site morbidity [17]. Despite harvesting the nerve from a donor site, Miloro
and Stoner found that most patients under the age of 38 tolerated harvest of the sural
nerve without signicant neurosensory disturbances or morbidity of the donor site
if functional sensory recovery was achieved at the trigeminal nerve [20].
Microvascular free tissue transfer offers great versatility in the selection of tissue
for reconstruction of head and neck defects. The utilization of vascularized free
aps is indicated when extensive soft tissue and bone are included in tumor ablation
or an avulsive injury that requires reconstruction. The nerves contained in the following vascularized free aps may be used for nerve repair:
• The medial antebrachial [21] or the lateral cutaneous nerve of forearm [22]. In a
study of 22 patients who had glossectomy for oral carcinoma, Kuriakose found
that 77% of patients had sensory recovery within 8months after reconstruction
with a radial forearm free ap via the lateral antebrachial cutaneous nerve [23].
• The long thoracic nerve can be harvested when performing a scapula latissimus
dorsi free ap. Schultes etal. found that all ve patients had progressive return
of sensation when the long thoracic nerve was used to reconstruct the mental
nerve [24]. Pressure sensation returned for the ve patients at 3–4months post-
operatively. Pain sensation returned thereafter 2 months, with conversion to
hyperesthesia, lessening to normal after months 5 and 6. Four of the ve patients
were able to discriminate between sharp and blunt sensations after the fth
month, the last patient after 7months. At 6–7months, all patients were able to
discriminate between two points and recovered senses of vibration and light
touch in the original region of the mental nerve distribution. After 9months, four
patients had bilateral equal sensitivity.
• A case report by Tanaka etal. found that the lateral sural cutaneous nerve can be
anastomosed to the distal end of the remnant lAN using an epineural repair [25].
The mandible was reconstructed with a bula free ap that included the sural
nerve. The proximal ends of the right and left IAN were re-approximated to the
proximal and distal ends of the sural nerve. Sensations were measured using
Semmes-Weinstein monolaments. Tanaka et al. found that sensory recovery
was rst noted after 5 months and the quantitative results of the Semmes-
Weinstein test 45months after surgery ranged from 2.83 to 4.08.
Nerve allografts are decellularized conduits that serve as a temporary scaffold
for neural regeneration [26]. The decellularized allogenic nerve graft provides an
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unlimited source of graft with no associated donor site morbidity and reduces the
risk of immune rejection [17, 27]. Processed nerve allografts may be safely and
effectively used to reconstruct trigeminal sensory nerve defects between 5 and
70mm. Miloro etal. found that patients that had reconstruction of the IAN or LN
with allogeneic grafts reported a satisfaction score of 8.9 on the visual analogue
scale, as compared to the reported score of 8.1 for patients that had undergone direct
repair. He also reported an accelerated rate of functional sensory recovery as compared to direct neurorrhaphy or no intervention [28]. The study noted that indirect
graft nerve repair, using an allograft (AVANCE nerve graft), is associated with
improved objective and subjective nerve outcomes compared with direct nerve
repair [28]. Zuniga also reported that of his 16 patients reconstructed with an allogeneic nerve graft, 14 (87%) of them saw improvements in sensory function (87%)
[29]. Salomon reported a similar nding, stating that 85.7% of his patients reconstructed with the allogeneic nerve graft achieved some return of tactile sensation
and supercial pain without over-response [9]. Numerous publications have conrmed the safety and efcacy of using a cadaveric peripheral nerve allograft
(AVANCE, Axogen Corporation, Alachua, FL) to reconstruct the inferior alveolar
nerve (IAN) following non-ablative and ablative mandibular resection, mostly for
benign disease [1, 28–30]. Risks associated with the reconstruction include failure
to gain FSR; this approach is not associated with the donor site morbidity of autologous nerve grafts. It is important to note that even if only some sensation is regained,
this would be an improvement as opposed to no attempt at nerve reconstruction and,
consequently, no change in neurosensory function [17, 31]. It has been proposed
that acellular processed nerve allografts may replace autogenous nerve grafts [30].
V. A. Manon et al.
Conclusions
Iatrogenic injury or resection of the IAN and/or LNs as a result of oral and maxillofacial procedures can result in devastating physical and psychosocial complications for the patient, reducing their overall quality of life. These injuries can
negatively impact the patients’ ability to eat and enjoy their food and impair social
interactions via deterioration of speech, sensory limitations causing retention of
food on the face and drooling, and increased self-conscious awareness associated
with their disabilities. Psychological consequences of these impairments may lead
to clinical depression. It is imperative that these potential complications and their
associated functional/sensory implications are discussed preoperatively and that
they are managed promptly and appropriately when they occur. Attention to the
patient’s psychosocial and functional disabilities deserves attention in order to
achieve holistic patient care.
Surgeons are encouraged to document functional sensory loss after these injuries
and perceived quality of life using patient surveys such as the OHIP-14 or SF-36.
Once physical and/or psychological disabilities are observed and documented,
prompt intervention or referral is crucial for successful clinical outcomes and patient
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satisfaction. Various treatment options are available to the head and neck surgeon:
direct neurorrhaphy, autogenous nerve grafts, vascularized free aps, and decellularized allogenic nerve grafts. Use of these techniques can result in signicant functional sensory recovery, improving the patients’ overall quality of life. When
possible, the surgeon is encouraged to consider maxillomandibular reconstruction
not only of the bone and soft tissues but also of the sensory nerves necessary for
human function.
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V. A. Manon et al.
Chapter 19
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Trigeminal Nerve Reconstruction
inMaxillofacial Surgery
RaymondP.Shupak, JeffreyHartgerink, CheukSunEdwinLai,
SimonYoung , AlexisM.Linnebur, ZacharyS.Peacock,
SrinivasaR.Chandra, AshishPatel, andJamesC.Melville
R. P. Shupak (*)
Department of Oral Medicine and Maxillofacial Surgery, Geisinger Commonwealth School
of Medicine, Geisinger Health System, Danville, PA, USA
e-mail: rshupak@geisinger.edu
J. Hartgerink
Chemistry and Bioengineering, Rice University, Houston, TX, USA
Undergraduate Studies, Rice University, Houston, TX, USA
e-mail: jdh@rice.edu
C. S. E. Lai
Rice University, Houston, TX, USA
e-mail: cl95@rice.edu
S. Young · J. C. Melville
Department of Oral and Maxillofacial Surgery, The University of Texas Health Science
Center at Houston, Houston, TX, USA
e-mail: Simon.Young@uth.tmc.edu; James.C.Melville@uth.tmc.edu
A. M. Linnebur
Carle Foundation Hospital, Urbana, IL, USA
e-mail: alexis.linnebur@carle.com
Z. S. Peacock
Oral and Maxillofacial Surgery, Massachusetts General Hospital (MGH), Boston, MA, USA
e-mail: zpeacock@partners.org
S. R. Chandra
Oral and Maxillofacial Surgery, Oregon Health Sciences School of Dentistry,
Portland, OR, USA
e-mail: chandrsr@ohsu.edu
A. Patel
Oral, Head and Neck Surgery, Head and Neck Surgical Associates, Portland, OR, USA
e-mail: Patela@head-neck.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and
Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_19
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