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Jacobs T, Mohammed S, Ziccardi V. Evaluating Lingual Nerve Repair Outcomes: A Systematic Review. J Oral Maxillofac Surg 2024; 82:1212-1223. [PMID: 39002552 DOI: 10.1016/j.joms.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE The lingual nerve (LN) is susceptible to injury during oral and maxillofacial procedures, leading to neurosensory deficits. Advances in microsurgical techniques necessitate a comprehensive review of overall effectiveness and influencing factors. METHODS A systematic review was performed via Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies. Inclusion criteria were full text availability, studies written in english, and studies published after 2000 reporting LN repair. The primary outcome was sensory improvement defined via functional sensory recovery (FSR) or neurosensory testing (NST). Sex, time from injury to repair, method of repair, and graft length were examined to see if each influenced outcomes. RESULTS A sample of 786 subjects across 17 studies was examined. Most patients were female (73.3%) and suffered injuries from third molar extractions (72.8%). Of the studies, 10 defined improvement by FSR with a total of 88.8% (500/563) of nerves achieving such. Of those achieving FSR, 91% did so within a year. The remaining 7 studies defined sensory improvement by individually setting various NST thresholds, with the combined improvement rate being 88.6% (203/229). Positive outcomes were achieved with graft lengths up to 70 mm. Results on time to repair were mixed. The methods of repairs were not different based on statistical analysis short of performing an equivalence trial. CONCLUSION Conclusions made from studies using FSR were similar to studies using NST, meaning the method of measuring outcomes does not seem to be a confounder. FSR is the superior scale due to being objective and standardized. LN repair produced high rates of sensory improvement, which is expected to occur within 1 year postoperative. Sex and graft length did not influence outcomes. More research is needed to determine the effect of time to repair on efficacy. Most methods of repair produced similar outcomes, suggesting multiple valid techniques exist.
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Affiliation(s)
- Tyler Jacobs
- Resident, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ.
| | - Saad Mohammed
- BA Candidate, New Jersey Institute of Technology, Newark, NJ
| | - Vincent Ziccardi
- Professor, Chair, and Associate Dean for Hospital Affairs, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ
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Jacobs T, Patil D, Ziccardi VB. Both Type I Bovine Collagen Conduits and Porcine Small Intestine Submucosa Conduits Result in Functional Sensory Recovery Following Peripheral Nerve Microsurgery: A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2024:S0278-2391(24)00697-9. [PMID: 39216509 DOI: 10.1016/j.joms.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/11/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE The study purpose was to measure and compare the time to functional sensory recovery (FSR) and incidence of FSR by 6 and 12 months between type I bovine collagen conduits versus porcine small intestine submucosa (SIS) conduits with primary neurorrhaphy for peripheral nerve injury repair. METHODS A systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted. The predictor variable was the type of conduit-either bovine collagen or porcine SIS. The primary outcome variable was the number of months between surgery and the patient achieving FSR. The secondary outcome variable was the proportion of patients who achieved FSR that did so by 6 and 12 months. A log-rank test was performed to evaluate the statistical significance of the differences observed in the overall time-to-FSR data and by 6 and 12 months. RESULTS We screened 67 publications of which 8 were included. The sample sizes were 137 and 96 patients for the bovine collagen and porcine SIS groups, respectively. The median time to FSR for the bovine collagen conduit group was 9 months (interquartile range: 6); the median time to FSR for the porcine SIS conduit group 6 months (interquartile range: 3 months) (P = .50). Of the patients who achieved FSR, 42% of patients with bovine collagen conduits and 64% of patients with porcine SIS conduits did so within 6 months (P < .01). Of the patients who achieved FSR, 94% of patients with bovine collagen conduits and 82% of patients with porcine SIS conduits did so within 12 months (P < .01). CONCLUSION Although a significant difference was found in the incidence of FSR at 6 and 12 months, no significant difference was found in overall time to FSR, supporting the use of either conduit for peripheral nerve repair.
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Affiliation(s)
- Tyler Jacobs
- Resident, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ.
| | - Disha Patil
- M.D. Candidate, Rutgers New Jersey Medical School, Newark, NJ
| | - Vincent B Ziccardi
- Professor, Chair, and Associate Dean for Hospital Affairs, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ
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Almohammadi T, Yates J, Aljohani M, Alshehri S. Surgical outcomes of the surgical techniques following management of iatrogenic trigeminal nerve injuries: A systematic review. Saudi Dent J 2024; 36:499-508. [PMID: 38690384 PMCID: PMC11056400 DOI: 10.1016/j.sdentj.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/24/2023] [Accepted: 12/27/2023] [Indexed: 05/02/2024] Open
Abstract
Objective To investigate the effectiveness of the microsurgical treatment in restoring full sensory recovery following trigeminal nerve injuries caused by iatrogenic oral and maxillofacial surgical interventions. Methods A detailed search was conducted on the Cochrane central register of controlled trials, Medline and Embase. Clinical studies with at least twelve months of follow up were included and assessment of risks of bias was made using the Robbin I assessment tool. Results Six studies were identified in the searches which include 227 patients. The lingual nerve was the most common injured nerve, followed by the inferior alveolar nerve. Third molar removal was the most frequent cause of nerve injury, followed by root canal treatment, pathology excision, coronectomy, orthognathic surgery, dental implants and then local anaesthetic injections. Overall, surgical interventions for nerve injuries showed neurosensory improvement postoperatively in the majority of patients. Conclusion Direct neurorrhaphy is still the gold-standard technique when the tension at the surgical site is minimal. Promising results have been noted on conduit applications following traditional repair or grafting. Further research is needed on the efficacy of allografting and conduit applications in nerve repair.
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Affiliation(s)
- Turki Almohammadi
- Department Oral and Maxillofacial Surgery, College of Dentistry, Jouf University, Sakaka, Saudi Arabia
| | - Julian Yates
- Faculty of Biology, Medicine and Health, Division of Dentistry, the University of Manchester, United Kingdom
| | - Marwan Aljohani
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Taibah University, Saudi Arabia
| | - Sami Alshehri
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arbia
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Kämmerer PW, Heimes D, Hartmann A, Kesting M, Khoury F, Schiegnitz E, Thiem DGE, Wiltfang J, Al-Nawas B, Kämmerer W. Clinical insights into traumatic injury of the inferior alveolar and lingual nerves: a comprehensive approach from diagnosis to therapeutic interventions. Clin Oral Investig 2024; 28:216. [PMID: 38488908 PMCID: PMC10942925 DOI: 10.1007/s00784-024-05615-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/10/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES This scoping review explores the risk and management of traumatic injuries to the inferior alveolar and lingual nerves during mandibular dental procedures. Emphasizing the significance of diagnostic tools, the review amalgamates existing knowledge to offer a comprehensive overview. MATERIALS AND METHODS A literature search across PubMed, Embase, and Cochrane Library informed the analysis. RESULTS Traumatic injuries often lead to hypo-/anesthesia and neuropathic pain, impacting individuals psychologically and socially. Diagnosis involves thorough anamnesis, clinical-neurological evaluations, and radiographic imaging. Severity varies, allowing for conservative or surgical interventions. Immediate action is recommended for reversible causes, while surgical therapies like decompression, readaptation, or reconstruction yield favorable outcomes. Conservative management, utilizing topical anesthesia, capsaicin, and systemic medications (tricyclic antidepressants, antipsychotics, and serotonin-norepinephrine-reuptake-inhibitors), proves effective for neuropathic pain. CONCLUSIONS Traumatic nerve injuries, though common in dental surgery, often go unrecorded. Despite lacking a definitive diagnostic gold standard, a meticulous examination of the injury and subsequent impairments is crucial. CLINICAL RELEVANCE Tailoring treatment to each case's characteristics is essential, recognizing the absence of a universal solution. This approach aims to optimize outcomes, restore functionality, and improve the quality of life for affected individuals.
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Affiliation(s)
- Peer W Kämmerer
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany.
| | - Diana Heimes
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Amely Hartmann
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Marco Kesting
- Department of Oral and Cranio-Maxillofacial Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glückstraße 11, 91054, Erlangen, Germany
| | - Fouad Khoury
- International Dental Implant Center, Private Clinic Schloss Schellenstein, Am Schellenstein 1, 59939, Olsberg, Germany
| | - Eik Schiegnitz
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Daniel G E Thiem
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Jörg Wiltfang
- Department of Oral and Maxillofacial Surgery, Christian Albrechts University, UKSH Campus Kiel, 24105, Kiel, Germany
| | - Bilal Al-Nawas
- Clinic of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 1, D-55131, Mainz, Germany
| | - Wolfgang Kämmerer
- Pharmacy Department, University of Augsburg, Medical Faculty, D-86156, Augsburg, Germany
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Jacobs T, Mohammed S, Ziccardi V. Assessing the Efficacy of Allogeneic Nerve Grafts in Trigeminal Nerve Repair: A Systematic Review. J Oral Maxillofac Surg 2024; 82:294-305. [PMID: 38182118 DOI: 10.1016/j.joms.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/09/2023] [Accepted: 12/10/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE Our primary objective was to assess the efficacy of allogeneic nerve grafts in inferior alveolar nerve or lingual nerve repair. We hypothesized that using allogeneic nerve grafts would be effective, as evidenced by achieving high rates of functional sensory recovery (FSR). Additionally, we looked if sex, time from injury to repair, etiology of nerve damage, and graft length affected outcomes. METHODS A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. PubMed and Scopus databases were searched using specific search strategies to generate eligible studies. Inclusion criteria encompassed studies reporting use of allogeneic grafts, assessing FSR using either Medical Research Council Scale or Neurosensory Testing, and published within the past 15 years. RESULTS Across 10 studies conducted between 2011 and 2023, analysis was performed on 149 patients and 151 reconstructed nerves. Allogeneic nerve grafts showed an average FSR rate of 88.0%. Kaplan-Meier analysis of time to FSR postoperatively revealed that of those achieving FSR, 80% achieved it within 6 months and 98% achieved it by 1 year. The mean graft length was 29.92 mm ± 17.94 mm. The most common etiology for nerve damage was third molar extractions (23.3%). Sex distribution among patients revealed that 85 were female (57.0%) and 64 were male (43.0%). CONCLUSION Our primary hypothesis was supported as nerve allografts achieved high rates of FSR. FSR was achieved in normative timeframes, which is 6 to 12 months postoperatively. Furthermore, allografts reduced the risk of posttraumatic trigeminal neuropathy. Time from injury to repair, graft length, etiology of nerve damage, and sex did not affect FSR. As the assessed variables in our study did not affect outcomes, there needs to be a more nuanced approach to understanding and addressing various factors influencing sensory recovery.
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Affiliation(s)
- Tyler Jacobs
- Resident, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ.
| | - Saad Mohammed
- BA Candidate, New Jersey Institute of Technology, Newark, NJ
| | - Vincent Ziccardi
- Professor, Chair, and Associate Dean for Hospital Affairs, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ
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Ostrowski P, Bonczar M, Wilk J, Michalczak M, Czaja J, Niziolek M, Sienkiewicz J, Szczepanek E, Chmielewski P, Iskra T, Gregorczyk-Maga I, Walocha J, Koziej M. The complete anatomy of the lingual nerve: A meta-analysis with implications for oral and maxillofacial surgery. Clin Anat 2023; 36:905-914. [PMID: 36864652 DOI: 10.1002/ca.24033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
Lingual nerve (LN) injury during surgical procedures in the third molar region warrants a detailed study of its common pathway and important variations. Therefore, the objective of this study was to analyze and compile the multiple anatomical variations of the LN for use in oral and maxillofacial surgery. It is anticipated that the results of the present meta-analysis may help to minimize the possible complications when performing procedures associated with this anatomical entity. Major online databases such as PubMed, Web of Science, Scopus, Embase were used to gather all relevant studies regarding the LN anatomy. The results were established based on a total of 1665 LNs. The pooled prevalence of the LN being located below the lingual/ alveolar crest was found to be 77.87% (95% CI: 0.00%-100.00%). The LN was located above the lingual/ alveolar crest in 8.21% (95% CI: 4.63%-12.89%) of examined nerves. The most common shape of the LN was established to be round with a prevalence of 40.96% (95% CI: 23.96%-59.06%), followed by oval at 37.98% (95% CI: 23.98%-53.02%) and flat at 25.16% (95% CI: 12.85%-39.77%). In conclusion, we believe that this is the most accurate and up-to-date study regarding the anatomy of the LN. The LN was found to be located below the lingual/alveolar crest in 77.87% of the cases. Furthermore, the LN was found to enter the tongue under the submandibular duct in 68.39% of the cases. Knowledge about the anatomy of the LN is crucial for numerous oral and maxillofacial procedures such as during the extraction of the third molar.
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Affiliation(s)
- Patryk Ostrowski
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Michał Bonczar
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Jakub Wilk
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Michalczak
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Julia Czaja
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Martha Niziolek
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Justyna Sienkiewicz
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Elżbieta Szczepanek
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Tomasz Iskra
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
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Frostadottir D, Chemnitz A, Johansson OT LJ, Holst J, Dahlin LB. Evaluation of Processed Nerve Allograft in Peripheral Nerve Surgery: A Systematic Review and Critical Appraisal. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5088. [PMID: 37383478 PMCID: PMC10299771 DOI: 10.1097/gox.0000000000005088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
Peripheral nerve injuries cause substantial problems when not treated properly. A specific problem is reconstruction of nerve defects, which can be treated in different ways. This study aimed to systematically review whether processed nerve allograft (PNA) is justified in reconstruction of a nerve defect in patients after posttraumatic or iatrogenic peripheral nerve injury and to compare PNA with other established methods. Methods A systematic review with a focused question, PICO (patient, intervention, comparison, outcome) and constraints, was performed. A structured literature search, including several databases, was done to evaluate the existing evidence for outcomes and postoperative complications related to PNA. The certainty of evidence was classified according to Grading of Recommendations, Assessment, Development and Evaluations. Results No conclusions, concerning differences in outcome of nerve reconstruction using PNA compared with the use of nerve autograft or conduits, could be drawn. The level of certainty for all evaluated outcomes was very low (⊕◯◯◯). Most published studies lack a control group to patients treated with PNA; being only descriptive, making it difficult to compare PNA with established methods without substantial risk of bias. For studies including a control group, the scientific evidence was of very low certainty, due to a low number of included patients, and large, undefined loss of patients during follow-up, rendering a high risk of bias. Finally, the authors often had financial disclosures. Conclusion Properly conducted randomized controlled trial studies on the use of PNA in reconstruction of peripheral nerve injuries are needed to establish recommendations in clinical practice.
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Affiliation(s)
- Drifa Frostadottir
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
| | - Anette Chemnitz
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Jan Holst
- Department of Vascular Disease, Skåne University Hospital, Malmö, Sweden
- Department of Research and Education, HTA syd, Skåne University Hospital, Lund, Sweden
| | - Lars B. Dahlin
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Is Surgical Repair With Nerve Allograft More Cost-Effective Than Non-Surgical Management for Persistent Trigeminal Neuropathy? Initial Assessment With Markov Model. J Oral Maxillofac Surg 2023:S0278-2391(23)00176-3. [PMID: 36893794 DOI: 10.1016/j.joms.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Persistent trigeminal neuropathy (PTN) is associated with high rates of depression, loss of work, and decreased quality of life (QoL). Nerve allograft repair can achieve functional sensory recovery in a predictable manner; however, it bears significant upfront costs. In patients suffering from PTN, is surgical repair with allogeneic nerve graft, when compared to non-surgical therapy, a more cost-effective treatment option? MATERIALS AND METHODS A Markov model was constructed with TreeAge Pro Healthcare 2022 (TreeAge Software, Massachusetts) to estimate the direct and indirect costs for PTN. The model ran for 40 years with 1-year-cycles on a 40-year-old model patient with persistent inferior alveolar or lingual nerve injury (S0 to S2+) at 3 months without signs of improvement, and without dysesthesia or neuropathic pain (NPP). The 2 treatment arms were surgery with nerve allograft versus non-surgical management. There were 3 disease states, functional sensory recovery (S3 to S4), hypoesthesia/anesthesia (S0 to S2+), and NPP. Direct surgical costs were calculated using the 2022 Medicare Physician Fee Schedule and verified with standard institutional billing practices. Non-surgical treatment direct costs (follow-up, specialist referral, medications, imaging) and indirect costs (QoL, loss of employment) were determined from historical data and the literature. Direct surgical costs for allograft repair were $13,291. State-specific direct costs for hypoesthesia/anesthesia were $2,127.84 per year, and $3,168.24 for NPP per year. State-specific indirect costs included decreased labor force participation, absenteeism, and decreased QoL. RESULTS Surgical treatment with nerve allograft was more effective and had a lower long-term cost. The incremental cost-effectiveness ratio was -10,751.94, indicating surgical treatment should be utilized based on efficiency and cost. With a willingness-to-pay threshold of $50,000, the net monetary benefits of surgical treatment are $1,158,339 compared to $830,654 for non-surgical treatment. With a standard threshold incremental cost-effectiveness ratio of 50,000, the sensitivity analysis shows that surgical treatment would remain the preferred choice based on efficiency even if surgical costs were doubled. CONCLUSION Despite high initial costs of surgical treatment with nerve allograft for PTN, surgical intervention with nerve allograft is a more cost-effective treatment option when compared to non-surgical therapy.
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Fujita S, Tojyo I, Nakanishi T, Suzuki S. Comparison of prognosis in two methods for the lingual nerve repair: direct suture with vein graft cuff and collagen allograft method. Maxillofac Plast Reconstr Surg 2022; 44:6. [PMID: 35229188 PMCID: PMC8885916 DOI: 10.1186/s40902-022-00335-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
No studies have compared the outcomes of direct perineurial suture with vein graft cuff repair and indirect collagen allograft repair of the lingual nerve following an injury. Therefore, we evaluated and compared the outcomes of each over a 1-year observation period. We retrospectively assessed 20 patients who had undergone microneurosurgical repair of unilateral lingual nerve injuries at the Wakayama Medical University Hospital between May 2015 and March 2019. We utilized two different methods for lingual nerve repair, i.e., direct perineurial repair with a vein graft cuff and interpositional collagen allograft repair. Sensory and taste function in the lingual nerve were preoperatively evaluated using a static two-point discrimination test, superficial pain/tactile sensation test, tests for the pressure pain threshold (Semmens-Weinstein monofilament), test for thermal discrimination hot and cold sensation, and a taste discrimination test. These tests were performed again at 6 and 12 months postoperatively.
Results
Compared to the preoperative conditions, all patients showed improved sensory reactions. Functional sensory recovery outcomes were defined by Pogrel’s criteria, Medical Research Council Scale grades, and functional sensory recovery. In each group, all patients improved after the operation. However, the operation time was significantly shorter for an interpositional collagen allograft repair as compared to that for a direct perineurial repair with a vein graft cuff.
Conclusions
There were no statistically significant differences between the two repair Methods, except for the operation time. Both methods led to satisfactory results for all criteria. From an economic point of view, direct perineurial repair with a vein graft cuff is meaningful; however, the esthetic effect on the donor site should be considered. Conversely, interpositional collagen allograft repair has the advantage of a greatly shortened operation time.
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Weyh A, Pucci R, Valentini V, Fernandes R, Salman S. Injuries of the Peripheral Mandibular Nerve, Evaluation of Interventions and Outcomes: A Systematic Review. Craniomaxillofac Trauma Reconstr 2021; 14:337-348. [PMID: 34707795 PMCID: PMC8543599 DOI: 10.1177/19433875211002049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Trigeminal nerve injuries are common and there is currently no consensus on both timing and type of intervention to achieve the best outcomes. A systematic review was performed to compare the outcomes of the many different types of therapeutic interventions for nerve injury. PubMed, EBSCO, and Cochrane Review databases were used to search for studies published from January 1, 2000 to December 31, 2019. Included studies detailed treatment of an injury to peripheral branches of the trigeminal nerve, either known transection or injury causing persistent alteration in sensation. The primary outcome was functional sensory recovery via the Medical Research Council scale. Twenty studies were included, detailing outcomes of 608 subjects undergoing intervention for 622 nerve injuries. Surgical interventions were able to achieve functional sensory recovery in approximately >80% or more of the subjects. There was heterogeneity among how procedures were performed, timing to intervention, and methods of measuring recovery. The data of this study supports the ability of surgical intervention to achieve functional sensory recovery in a significant number of subjects, and found evidence for better outcomes with intervention closer to the time of injury.
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Affiliation(s)
- Ashleigh Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Resi Pucci
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy
| | - Valentino Valentini
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy
| | - Rui Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Salam Salman
- Department of Oral and Maxillofacial Surgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
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Miloro M, Zuniga JR. Does Immediate Inferior Alveolar Nerve Allograft Reconstruction Result in Functional Sensory Recovery in Pediatric Patients? J Oral Maxillofac Surg 2020; 78:2073-2079. [DOI: 10.1016/j.joms.2020.06.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
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12
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Atkins S, Kyriakidou E. Clinical outcomes of lingual nerve repair. Br J Oral Maxillofac Surg 2020; 59:39-45. [PMID: 32800402 DOI: 10.1016/j.bjoms.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Lingual nerve injury, a well-described complication of third molar removal, may result in permanent lingual sensory deficit leading to symptoms including lost or altered sensation, inadvertent tongue biting, and the development of unpleasant neuropathic pain, with consequent impaired quality of life. We analysed outcomes of a prospective case series to determine whether direct anastomosis of the lingual nerve results in improved sensory recovery and reduced neuropathic pain, and whether delayed surgery is worthwhile. In 114 patients who underwent nerve repair at our nerve injury clinic following damage sustained during mandibular third molar removal, sensory deficit was assessed before and after surgery using a questionnaire and visual analogue scales (VAS) to assess pain, tingling, and discomfort. Neurosensory tests were utilised to evaluate light touch, pin-prick, and two-point discrimination thresholds. Subjectively, 94% patients felt their sensation had improved following nerve repair, with significant reductions in the incidence of tongue biting (p<0.0001), impaired speech (p<0.0001), and neuropathic pain (p=0.0017). Quantitative neurosensory data showed highly significant improvements in light touch, pin-prick, and two-point discrimination (all p<0.0001), and VAS scores for pain (p=0.0145), tingling (p<0.0025), and discomfort (p<0.0001) were significantly reduced. Patients with high levels of pain preoperatively (VAS>40) showed highly significant reductions in pain (p<0.0001). No correlation was found between surgical outcome and patient's age or delay until surgery. Lingual nerve repair results in good sensory outcomes and significant improvements in the incidence and degree of neuropathic pain, even when delayed.
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Affiliation(s)
- S Atkins
- Unit of Oral and Maxillofacial Surgery, School of Clinical Dentistry, University of Sheffield, UK.
| | - E Kyriakidou
- Unit of Oral and Maxillofacial Surgery, School of Clinical Dentistry, University of Sheffield, UK.
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Kasper M, Deister C, Beck F, Schmidt CE. Bench-to-Bedside Lessons Learned: Commercialization of an Acellular Nerve Graft. Adv Healthc Mater 2020; 9:e2000174. [PMID: 32583574 DOI: 10.1002/adhm.202000174] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/11/2020] [Indexed: 12/19/2022]
Abstract
Peripheral nerve injury can result in debilitating outcomes including loss of function and neuropathic pain. Although nerve repair research and therapeutic development are widely studied, translation of these ideas into clinical interventions has not occurred at the same rate. At the turn of this century, approaches to peripheral nerve repair have included microsurgical techniques, hollow conduits, and autologous nerve grafts. These methods provide satisfactory results; however, they possess numerous limitations that can prevent effective surgical treatment. Commercialization of Avance, a processed nerve allograft, sought to address limitations of earlier approaches by providing an off-the-shelf alternative to hollow conduits while maintaining many proregenerative properties of autologous grafts. Since its launch in 2007, Avance has changed the landscape of the nerve repair market and is used to treat tens of thousands of patients. Although Avance has become an important addition to surgeon and patient clinical options, the product's journey from bench to bedside took over 20 years with many research and commercialization challenges. This article reviews the events that have brought a processed nerve allograft from the laboratory bench to the patient bedside. Additionally, this review provides a perspective on lessons and considerations that can assist in translation of future medical products.
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Affiliation(s)
- Mary Kasper
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
| | | | | | - Christine E. Schmidt
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
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Kogan M, Lee KC, Chuang SK, Ziccardi VB. Outcomes of Direct Lingual Nerve Repair After an Injury: A Systematic Review. J Oral Maxillofac Surg 2020; 79:697-703. [PMID: 32745534 DOI: 10.1016/j.joms.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to conduct a systematic review with meta-analysis to investigate the outcomes of direct lingual nerve repair after injury. MATERIALS AND METHODS The studies in this review were compiled by using PubMed/Medline and ScienceDirect, which were searched by a single reviewer (M.K.) from their inception until March 10, 2020. Two independent reviewers (M.K. and V.B.Z.) who were blinded to each other's assessments reviewed full-text articles to assess for study inclusion. Outcomes were dichotomized as either functional sensory recovery (FSR) or no FSR. Clinical testing must have been assessed at a minimum of 6 months postoperatively. FSR was defined as grade S3, S3+, or S4 on the British Medical Research Council scale of neurosensory function. Studies were only eligible if they provided the number of patients treated with conduits or time from injury to repair and the associated rates of FSR with each intervention. RESULTS The initial search using the key terms yielded 4,921 results, which was then eventually filtered down to 6 articles after multiple levels of appraisal. Five articles were retrospective cohort studies and 1 was a randomized controlled study. Four of the 6 studies reported an FSR of grade S3 or higher in 85% or more of the patients. Conduit use was not associated with a significantly greater likelihood of achieving FSR (pooled risk ratio = 1.10; 95% confidence interval, 0.96 to 1.27; P = .17). Repair within 6 months was associated with significantly improved likelihood of achieving FSR (pooled risk ratio = 0.84; 95% confidence interval, 0.71 to 0.99; P = .04). CONCLUSIONS The use of conduits during repair was not associated with clinically significant increased FSR. Early repair was associated with a beneficial effect on FSR; however, heterogeneity was an issue with the studies. There is a lack of strong evidence owing to the nature of studies analyzed and the need for further research is required.
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Affiliation(s)
- Mark Kogan
- Private Practitioner, Florida Center for Oral & Maxillofacial Surgery, Pembroke Pines, FL.
| | - Kevin C Lee
- Senior Resident, Division of Oral and Maxillofacial Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Sung-Kiang Chuang
- Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA; and Private Practice, Brockton Oral and Maxillofacial Surgery Inc.; Attending, Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA
| | - Vincent B Ziccardi
- Professor, Chair and Residency Director, Associate Dean of Hospital Affairs, Chief of Service, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, University Hospital, Newark, NJ
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Treatment of Neuroma-induced Chronic Pain and Management of Nerve Defects with Processed Nerve Allografts. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2467. [PMID: 32537284 PMCID: PMC7288900 DOI: 10.1097/gox.0000000000002467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/02/2019] [Indexed: 01/19/2023]
Abstract
Symptomatic neuromas can cause significant chronic pain and negatively impact quality of life. Symptoms often persist despite narcotics and nonoperative interventions, which are largely ineffective. With the opioid crisis, treatments for chronic pain that limit narcotics are needed. Traditional surgical options may result in neuroma recurrence. Autograft reconstruction often results in donor-site morbidity. Processed nerve allografts facilitate axonal growth, nerve regeneration, and eliminate donor-site morbidity. Methods A literature review was performed to identify studies in which chronic neuroma pain was treated with excision and processed nerve allograft reconstruction. PubMed was queried, and data from the studies were grouped into treatment effective and ineffective groups. Statistical analyses were performed on these groups, and further subgroup analysis was performed on overall change of preoperative and postoperative pain scores using a paired t test. Results Seven studies fulfilled inclusion criteria yielding 42 patients. Greater than 90% of patients had improvement of pain postoperatively. The preoperative and postoperative pain scores could be determined for 40 patients. The mean preoperative score was 7.9, and the mean postoperative score was 3.54. These results were statistically significant using a paired t test with a P value of <0.001. Conclusions Chronic pain resulting from symptomatic neuromas can be treated with neuroma excision and nerve stump reconstruction with processed nerve allograft. This obviates autograft-associated donor-site morbidity and provides a platform to potentially restore sensation to the involved nerve whenever a distal nerve end is available. Addressing the root cause is an important paradigm shift for treating symptomatic neuromas.
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Leung YY. Management and prevention of third molar surgery-related trigeminal nerve injury: time for a rethink. J Korean Assoc Oral Maxillofac Surg 2019; 45:233-240. [PMID: 31728330 PMCID: PMC6838349 DOI: 10.5125/jkaoms.2019.45.5.233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022] Open
Abstract
Trigeminal nerve injury as a consequence of lower third molar surgery is a notorious complication and may affect the patient in long term. Inferior alveolar nerve (IAN) and lingual nerve (LN) injury result in different degree of neurosensory deficit and also other neurological symptoms. The long term effects may include persistent sensory loss, chronic pain and depression. It is crucial to understand the pathophysiology of the nerve injury from lower third molar surgery. Surgery remains the most promising treatment in moderate-to-severe nerve injuries. There are limitations in the current treatment methods and full recovery is not commonly achievable. It is better to prevent nerve injury than to treat with unpredictable results. Coronectomy has been proved to be effective in reducing IAN injury and carries minimal long-term morbidity. New technologies, like the roles of erythropoietin and stem cell therapy, are being investigated for neuroprotection and neural regeneration. Breakthroughs in basic and translational research are required to improve the clinical outcomes of the current treatment modalities of third molar surgery-related nerve injury.
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Affiliation(s)
- Yiu Yan Leung
- Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Hong Kong, Hong Kong
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17
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Reconstructive Options for Inferior Alveolar and Lingual Nerve Injuries After Dental and Oral Surgery. Ann Plast Surg 2019; 82:653-660. [DOI: 10.1097/sap.0000000000001783] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Altafulla J, Iwanaga J, Lachkar S, Prickett J, Dupont G, Yilmaz E, Ishak B, Litvack Z, Tubbs RS. The Great Auricular Nerve: Anatomical Study with Application to Nerve Grafting Procedures. World Neurosurg 2019; 125:e403-e407. [PMID: 30703599 DOI: 10.1016/j.wneu.2019.01.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND When it comes to autogenous nerve grafting, the sural and great auricular nerve (GAN) are the 2 nerves predominately used for trigeminal and facial nerve repair. Arising from the second and third cervical ventral rami, the GAN emerges from the posterior border of the sternocleidomastoid coursing superiorly and anteriorly toward the ear. METHODS Eleven sides from 5 Caucasian and 1 Asian cadaveric heads (all fresh-frozen) were used. One man and 5 women were used with an age at death ranging from 57 to 91 years, with a mean of 80.3 years. Measurements were made from the inferior border of the ear to the GAN, the GAN to the external jugular vein, and the inferior border of the mastoid process to the GAN; the proximal, medial, and distal diameters of the GAN and the length of the GAN that was obtained from this exposure were also measured. RESULTS The mean distance from the inferior border of the mastoid process to the GAN, inferior border of the ear to the GAN, and GAN to the external jugular vein was 27.71, 31.03, and 13.28 mm, respectively. The mean length of the GAN was 74.86 mm. The mean diameter of its distal, middle, and proximal portions was 1.51, 1.38, and 1.58 mm, respectively. CONCLUSIONS The GAN is an excellent option for use in nerve grafting for repair of, for example, facial dysfunction. In this study, we review our measurements, techniques for identification, and dissecting techniques for the GAN. The proximity to the operative area and minimal complications associated with GAN grafting might contribute to improved patient satisfaction and better outcomes regarding functional restoration.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Neurosurgery Department, Hospital Santo Tomas, Panama
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA; Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Japan; Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan.
| | | | - Joshua Prickett
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Graham Dupont
- Seattle Science Foundation, Seattle, Washington, USA
| | - Emre Yilmaz
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Basem Ishak
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Miloro M, Markiewicz MR. Virtual Surgical Planning for Inferior Alveolar Nerve Reconstruction. J Oral Maxillofac Surg 2017; 75:2442-2448. [DOI: 10.1016/j.joms.2017.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
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Shimoo Y, Yamamoto M, Suzuki M, Yamauchi M, Kaketa A, Kasahara M, Serikawa M, Kitamura K, Matsunaga S, Abe S. Anatomic and Histological Study of Lingual Nerve and Its Clinical Implications. THE BULLETIN OF TOKYO DENTAL COLLEGE 2017; 58:95-101. [PMID: 28724864 DOI: 10.2209/tdcpublication.2016-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although the risk of injuring the lingual nerve in the mandibular molar area during dental treatment is high, it can be repaired by nerve grafting. However, from the perspective of clinical dentistry, the pathway and histomorphometric characteristics of this nerve remain to be documented in detail. The purpose of the present study was to morphologically elucidate the pathway of the lingual nerve to clarify its significance in a clinical setting. A histomorphometric analysis was also performed in consideration of nerve grafting. The vertical distance between the occlusal plane and the superior margin of the lingual nerve showed a gradual decrease from the premolar toward the distal molar area. This suggests that the risk of injuring the lingual nerve increases gradually toward the distal area. The average total fascicular area of the lingual nerve was 1.90 mm2, which was larger than that of the sural nerve. It is the first-choice donor nerve for grafting. Therefore, even though the total fascicular area of the donor nerve is a little smaller than that of the recipient nerve, nerve grafting should be successful.
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Posnick J, Choi E, Singh N. Lingual nerve injury in association with sagittal ramus osteotomy and bicortical screw fixation: a review of 523 procedures in 262 subjects. Int J Oral Maxillofac Surg 2016; 45:1445-1451. [DOI: 10.1016/j.ijom.2016.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
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Cox B, Zuniga JR, Panchal N, Cheng J, Chhabra A. Magnetic resonance neurography in the management of peripheral trigeminal neuropathy: experience in a tertiary care centre. Eur Radiol 2016; 26:3392-400. [PMID: 26795500 DOI: 10.1007/s00330-015-4182-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/14/2015] [Accepted: 12/18/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This tertiary care experience examines the utility of magnetic resonance neurography (MRN) in the management of peripheral trigeminal neuropathies. MATERIALS AND METHODS Seventeen patients with clinically suspected peripheral trigeminal neuropathies (inferior alveolar nerve and lingual nerve) were imaged uniformly with 1.5-T examinations. MRN results were correlated with clinical and surgical findings in operated patients and the impact on clinical management was assessed. RESULTS Clinical findings included pain (14/17), sensory changes (15/17), motor changes (2/17) and palpable masses (3/17). Inciting events included prior dental surgery (12/17), trauma (1/17) and idiopathic incidents (4/17). Non-affected side nerves and trigeminal nerves in the intracranial and skull base course were normal in all cases. Final diagnoses on affected sides were nerve inflammation (4/17), neuroma in continuity (2/17), LN transection (1/17), scar entrapment (3/17), infectious granuloma (1/17), low-grade injuries (3/17) and no abnormality (3/17). Associated submandibular gland and sublingual gland oedema-like changes were seen in 3/17 cases because of parasympathetic effects. Moderate-to-excellent MRN-surgical correlation was seen in operated (8/17) patients, and neuroma and nerve transection were prospectively identified in all cases. CONCLUSION MRN is useful for the diagnostic work-up of suspected peripheral trigeminal neuropathy patients with significant impact on clinical management and moderate-to-excellent correlation with intra-operative findings. KEY POINTS • MRN substantially impacts diagnostic thinking and management in peripheral trigeminal neuropathy. • MRN has moderate-to-excellent correlation with intra-operative findings. • MRN should be considered in pre-surgical planning of peripheral trigeminal neuropathy subjects.
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Affiliation(s)
- Brian Cox
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9178, USA
| | - John R Zuniga
- Department of Oral & Maxillofacial Surgery, Surgery, Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Neeraj Panchal
- Department of Oral Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Cheng
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9178, USA.
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