Stages IAN injury management procedures
I Stage
General risk factors identification
Record of general risk factors. Patients must sign informed consent form. Clinicians must perform a neurosensory examination of mandibular nerve function before placing the implant. It should be taken on account the age and gender of the patient, anatomical and radiological risk factors in operation planning.
II Stage
Intraoperative risk factors identification
Record of intraoperative risk factors. If present, patient is immediately assigned to IAN injury patient group.
III Stage
Patient complaints identification
Contact with patient after local anaesthesia wears off. If patient has any complaints related with corresponding IAN sensory disturbances, patient is immediately assigned to IAN injury patient group.
IV Stage
Postoperative examination, postoperative risk factors evaluation and diagnosis statement
Neurosensory examination for assessment of the severity of the lesion. Neurosensory deficit area mapping and photographing it to compare with future photographs.
Radiographic examination for localization of the lesion documentation and confirmation whether INA injury has been caused by the implant.
Postoperative risk factors evaluation it is important to evaluate severity of the injury, the time elapsed since the injury and the proximity of the injury to the cell body.
Diagnosis statement based on patient complaints, IAN neurosensory and radiographic examination results.
V Stage
Treatment
Psychological treatment: immediate information, explanation, support.
Physiological treatment: implant removal when implant is in any contact with mandibular canal or there are symptoms of IAN sensory deficit. Cleaning of any irritant (bone debris, hematoma) in close approximation to the neurovascular bundle if possible.
Medicament treatment: three weeks course of steroids and NSAIDs.
- Topically 1 ml of intravenous form of dexamethasone (4 mg/ml).
- Oral dexamethasone 4 mg 2 tablets AM for 3 days and 1tablet AM for next 3 days or oral prednisolone 1 mg per kg per day (maximum 80 mg).
- Alternatively or as an adjunct high dose of NSAIDs medication (such as ibuprofen [800 milligrams] three times per day).
Cryotherapy: the paraneural tissues should have ice applied intensely for the first 24 hours postoperatively and then episodically for the first week.
Additional treatment:
- pharmacologic agents include antidepressants, anticonvulsants, antisympathetic agents, and topical medications.
- physiologic therapies can be indicated and prescribed by a nerve specialist. This treatment include transcutaneous electric nerve stimulation, acupuncture, and low level laser therapy.
VI Stage
1 week postoperative examination
Neurosensory examination: for monitoring of the IAN sensory function recovery. Neurosensory deficit area mapping and photographing it to compare with previous photographs. If paresthesia is present, neurosensory examination should be continued every week for 3 weeks and later every 2 - 3 weeks for 12 weeks.
Clinical examination: for assessment of postoperative area healing, hematoma, oedema reduction.
VII Stage
1 week postoperative treatment
Psychological treatment: patient should feel psychological support.
Medicamental treatment: oral NSAIDs medication (such as ibuprofen [800 milligrams] three times per day) should be continued for 3 weeks. If necessary additional 3 weeks of NSAIDs may be prescribed during 12 weeks postoperation.
Microneurosurgical treatment: if IAN transection was observed intraoperatively or if there is dysesthesia or complete anaesthesia in innervation zone, referral to a microneurosurgeon is indicated.
Aditional treatment: pharmacologic, physiologic therapies can be prescribed if indicated.
VIII Stage
12 weeks postoperative examination
Neurosensory examination: for monitoring of the IAN sensory function recovery. Neurosensory deficit area mapping and photographing it to compare with previous photographs.
IX Stage
12 weeks postoperative treatment
Medicament treatment: can be prescribed according to indications.
Microneurosurgical treatment: should be prescribed if there are no signs of improvement.
Aditional treatment: pharmacologic, physiologic therapies can be prescribed if indicated.