Recommendations for management of trigeminal nerve defects based on a critical appraisal of the literature.
OBJECTIVE
Management of trigeminal nerve injuries continues to challenge oral and maxillofacial surgeons. The purpose of this review article is to apply the principles of evidence-based medicine (E-BM) to determine the optimal operative technique for managing defects involving the inferior alveolar (IAN) or lingual nerves when direct (ie, primary) repair is not feasible.


METHODS
To address the research purpose, the four steps of the E-BM critical appraisal process were applied: 1) identify the clinical problem, 2) efficiently search the literature, 3) select relevant articles and apply rules of evidence, and 4) apply the findings to patient care. Parameters for the literature search included using Medline to identify English language articles, publication dates from 1986 through 1996, and studies involving human subjects.


RESULTS
The studies reviewed showed that the clinical literature on operative management of trigeminal nerve injuries is sparse, preoperative and postoperative neurosensory examinations are poorly documented, and the data are derived completely from reports using case series methods. Given these limitations, the available literature suggests that 1) tension-free, primary (direct) suture repair of an injured nerve, if possible, provides optimal results; 2) if direct repair is not possible, autogenous nerve grafts should be used for acute injuries, for example, immediate nerve repair after tumor resection or at the time of acute repair after traumatic injury; and 3) if direct repair is not possible, autogenous nerve grafts or hollow conduits (entubulization) to bridge the defect are equally successful for delayed reconstruction of gaps of 3 cm or smaller.


CONCLUSIONS
Based on the weakness of the current literature, recommendations for future research include 1) better standardization and documentation of sensory deficits resulting from nerve injuries and their recovery, 2) using multicenter studies to accumulate large samples of patients rapidly, 3) using case series or prospective cohort study designs to assess the value of operative management of nerve injuries, and 4) progressing to randomized clinical trials to ascertain the optimal operative management of nerve injuries.
Dodson
T B
TB
Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
Kaban
L B
LB
D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002648:Child; D015331:Cohort Studies; D019317:Evidence-Based Medicine; D005240:Feasibility Studies; D006801:Humans; D007440:Intubation / Q000295:instrumentation; D008036:Lingual Nerve / Q000503:physiopathology / Q000601:surgery; D061222:Lingual Nerve Injuries; D008340:Mandibular Nerve / Q000503:physiopathology / Q000601:surgery; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009460:Neurologic Examination; D005791:Patient Care; D010525:Peripheral Nerves / Q000637:transplantation; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D012677:Sensation / Q000502:physiology; D012678:Sensation Disorders / Q000209:etiology; D013536:Suture Techniques; D014182:Transplantation, Autologous; D014276:Trigeminal Nerve / Q000503:physiopathology / Q000601:surgery; D061221:Trigeminal Nerve Injuries