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in conjunction with a neuro‑anatomically correlated pain immediately postoperatively before pain is well established.
distribution and sensory abnormalities within the area of Psychological support and the volunteer of information by
pain. There should be partial or complete sensory loss the surgeon are also important at this time.
in all or part of the painful area, and confirmation of a Surgical management
lesion or disease by quantitative sensory testing, surgical Early repair of nerve injury has been deemed to be the
evidence, imaging, clinical neurophysiology, and/or most critical factor in the surgical management and
biopsy. [23]
prevention of neuropathic pain. For example, once the
Neuropathic pain should also be differentiated from neuropathic pain has set in, late surgical trigeminal nerve
other similar orofacial pain. The differential diagnosis of repair will not improve the patient’s symptoms. When
[20]
neuropathic pain includes inflammatory pain, traumatic an iatrogenic nerve injury is suspected, regular follow‑up
trigeminal neuropathy, persistent idiopathic facial pain is advised. If there is no improvement during 10‑12 weeks
(atypical facial pain), atypical odontalgia, complex regional of follow‑up or there are complaints of dysesthesia,
pain syndrome, and trigeminal neuralgia. [23] surgical exploration, localization, and immediate repair or
repair within days is advised. Repair should be carried out
MANAGEMENT with a tension‑free approximation.

Neuropathic pain tends to be long‑lasting, although PREVENTION
some patients recover completely, and others may find
relief with pharmacotherapy and learn to cope with Patient profiling should be done and identification of
their symptoms. Neuropathic pain is treated mainly with risk factors for developing neuropathic pain made in
anti‑depressants and anti‑epileptics, whereas simple all patients scheduled for orthognathic surgery. Proper
analgesics are not efficacious. Management of pain localization of the IAN before BSSO is also an essential
should be tailored to the individual patient on the basis preventive step. The advent of cone beam CT has made
of pain type(s), the causative disease(s), and psychosocial IAN canal assessment in three‑dimensions possible.
aspects. Furthermore, the development and modification of

Psychological management surgical techniques to reduce nerve injury during BSSO,
The assessment of neuropathic pain needs to include the such as safe surgical access to the mandibular nerve at
[40]
measurement of multiple aspects of the quality of life. the infratemporal fossa, and a modified technique to
[41]
Mood, physical and social functioning, and pain‑coping control the lower mandibular border cut, have been
strategies such as catastrophizing and social support critical in reducing the incidence of damage to the IAN.
are all important domains. As with other chronically Also useful is assessment of the IAN during BSSO, as by
painful conditions, cognitive‑behavioral interventions continuous monitoring of the status of the mandibular
may improve the quality of life in neuropathic pain nerve through observation of changes in the sensory
[31]
conditions. Reassurance and counseling of patients with action potentials of the nerve during surgery.
neuropathic pain will go a long way toward alleviating Severe nerve injuries often result from drilling too
their condition. deep past the bone into the nerve, or from placing
Medication the osteosynthesis screw on the nerve during fixation.
Neuropathic pain treatment remains unsatisfactory despite The use of intraoperative CT during BSSO allows for
[36]
a substantial increase in the number of trials. The use the intraoperative evaluation of osteosynthesis screw
of low‑dose anti‑depressants (amitriptyline, nortriptyline) penetration and depth. Intraoperative CT also allows for
is effective for symptomatic relief. carbamazepine, immediate assessment of treatment and provides the
[37]
phenytoin, and valproic acid are effective in ameliorating option to modify treatment if necessary. These preventive
diabetic neuropathy‑related pain. Other anti‑epileptic measures will help reduce the incidence of neuropathic
agents, including lamotrigine, oxcarbazepine, and pain and improve the quality of life of BSSO patients.
topiramate, show some benefit for the treatment of
neuropathic pain, although some studies have found them CURRENT TRENDS AND FUTURE
to be ineffective. [37,38] PROSPECTS

Topical 5% lidocaine patches offer a new therapeutic
alternative for patients suffering from neuropathic Because neuropathic pain after BSSO involves an injured
pain. These patches have been shown to be useful in a peripheral nerve which sends incorrect signals to neurons
subgroup of patients. [39] located in Meckel’s cave, a temporary inhibition of
such signals might be beneficial. Affordable long‑acting
In BSSO patients, an accurate preoperative patient liposomal local anesthetics, navigation guided procedures
history, as well as early identification of the patient with targeted at the exit of the mandibular nerve in the oval
severe or prolonged pain with the aim of initiating pain foramen, and miniaturized intra‑oral neurostimulators
treatment as early as possible, is the key to success. [29,34] applied proximal to the site of the nerve damage are
Kuhlefelt et al. suggest that patients with IAN damage possible treatment options that are currently under
[29]
after BSSO be put on neuropathic pain medication investigation.

174 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015