Mandibular Nerve Disturbances: Thoughts?

First, perform a map of any deficit on the patient's lip and/or chin. If there is no deficit, just the burning sensation, then don't remove any implants. This burning could be caused by mild axonotomesis due to stretching of the mental nerve either during exposure or from postoperative swelling, especially from the report that initially the pain was unilateral, but is now bilateral. Consider placing the patient on a brief dexamethasone regimen, dispense 8 tabs of 2 mg dexamethasone, with instructions to take 8 mg day one, 4 mg day two, 2 mg day three, 2 mg day four. In my practice, dexamethasone is prescribed for any significant flap elevation. being mindful of the patient's diabetic or other pertinent medical status. Anecdotally, I have had a patient swell tremendously due to a reaction to levaquin, to the point that I had to remove a well placed block graft. She had no parasthesia or dysesthesia for 1 day postoperatively, but had profound parasthesia as the swelling got worse, even on dexamethasone, over the following 3 days. It took 6 months for most of her parathesia to return, and complete resolution within a year. On another note, why would there be any flanges on what appears to be a fixed provisional restoration?

dr kim thank you so much for thorough explanation.. i will share ct images later this evening to help further in this discussion. in regards to ‘flanges; when i saw pt for follow up, she had an ‘indentation’ to not describe as an epulis formation on mandibular left near area of foramina. i retrieved the appliance and relieved it, and relieved some more. she immediately reported less pressure and burning from reduction of the flange.. side of denture. reqlly appreciate your input doc thabks again

Is the posterior left implant in sound bone at the coronal aspect? I personally would have an oral surgeon consult on what you call condensing ossification on the lower left just to make sure that is in fact what it is. Unless of course you are an oral surgeon. If you do remove any implants liquid dexamethasone could be placed where the implants are removed.

Dr. Kim I believe that the radiographs show at least three quadrants of florid lessons dysplasia, with the bilaterally and symmetrically distributed mixed lucent and opacified characteristics. Perhaps placement of the implants in the fibro-osseous lesion has produced a fibroproliferative response which has affected the mental nerve along it’s distribution??? Just a thought. Jim Sciubba

This is a very frightening looking Panorex film. It would be nice to see the preoperative panorex to get an idea of what these lesion are what brought them on.

Did I miss something? Is this a case of paresthesia? Or is OP saying the patient had pain a day after FULL MOUTH EXTRACTION AND IMPLANT PLACEMENTS? Why medrol dose pack? To treat pain? ?? Pain is quite a normal response after a fairly big surgery such as this.

Pre Op Pano

I saw pt this afternoon. Pt presents with pain’ on upper dentures also. Pt has no loss sensation any where however is ‘maybe more sensitive’ on LR. Pt has been reading up on symptoms online. I was planning to see her Tuesday for repositioning. Thanks to All for your words of experience. Miguel

Hi Please be assured that I do not mean to criticise here, but to encourage dialogue. I would be interested to see what others think of my opinion. Maybe I am particularly conservative, but personally, based on the pre-op OPG, I would have prescribed removal and replacement of UL1,2,5 teeth at most; and onward referral for definitive diagnosis of lesions in mandible. The All-On-Four concept, which is shown here, was devised as a relatively simple treatment, avoiding grafting, for replacement of a failed or failing upper dentition, which does not appear to be the case here.

As a GP, I do have much surgical experience with these full arch implant cases, but obviously not an expert. I feel that nothing should be done immediately other than watch and medicate for swelling (nothing wrong with this, decadron 10mg IM at surgery or the decreasing oral dose as mentioned). There is no way to see a base line the first week after surgery. What is the level of pain meds required to make the patient comfortable>that is really the issue. For what I call "major surgeries" as this is, I have an MD anesthesiologist do nasal-tracheal general anesthesia. The MD puts 10 mg decadron and then 30mg Toradol IV at surgery. I use DOCS protocol of 2 200mg oral ibuprophen and 2 500 mg acetamenophen post op as needed q 4-6 h. I say this because if a patient needs hydrocodone or oxycodone, it is a red flag for me because the "average patient " does not need this (I do 2 arches a week) and if I think something is wrong I will still wait and see how it settles out. Bilateral symptoms lead me to wait also since the same complication is usually not bilateral. One issue I have seen several times over the years is an implant (single implant) patient in severe pain, day after and not going away after a week. I waited 2 weeks and the implant floated out and pain went away; I feel bone compression necrosis and regardless of bone type and torque, the symptoms point to that. BTW I had one case of this and was referred 2 others to evaluate, all proved to have implants float out leaving a large defect to graft. This could be the case here with the lack of vascularity in the densified areas. Need to wait for normal inflammatory post op response to run it course.Just some thoughts. BTW, again, what was the pre op CBCT reading by the radiologist? As a GP, these dense and lucent areas would be of great concern and the radiologist may recommend the biopsy and I would probably send to OMFS. It is not undertreating the patient by doing one arch at a time, especially when doing the conversion at same appointment. Of course immediate load and conversion is another topic and can have its own complications leading to difficult patient and treatment management. Sincerely Leonard

I had a mini implant that broke removed and 2 implants placed in its spot. It was a lot of work with a lot of swelling. The implants were my bottom left first 2 molars. One month ago. My good canine tooth right next to the implant that was just put in that I never had a problem with is now hurting all the time. A sharp pain that goes from tooth to jaw. Nothing shows on X-ray. Dentist says implant is far enough away from canine. I’m really nervous and in pain. I don’t know what to do. Thank you.

Curious why did you need to reduce the flange There should be no flange. If there is then that could be the reason for the burning. Pressure that is not relieved