|Year : 2012 | Volume
| Issue : 1 | Page : 14-16
Trigeminal neuralgia surgical treatment using LASER
N Deenadayalan1, C Kumaravel2, Anumod Narayanan2
1 Dr. Julien's Laser Dental Clinic, pondybazzer, T. Nager, Chennai, Tamil Nadu, India
2 Department of OMFS, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||15-Sep-2012|
Dr. Julien's Laser Dental Clinic, A1 Sridevi Appartments, Lakshmi Kanthan Street, Pondybazzer, T. Nager, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Trigeminal neuralgia is an extremely painful and difficult condition to treat. Adding LASER is an edge cutting techonology which might help stop drugs and thereby the adverse effects. To describe the experience of using LASER in a patient with trigeminal neuralgia For NEUTECTOMY. A 47-year-old man presented with constant, severe pain in the right side of his face over the nasolabial groove for more than 11 months. The pain had been progressively worse and was usually precipitated by brushing his teeth, shaving, washing his face, eating, and talking. The patient's neurologist treated him with 150 mg/d of carbamazepine; when the pain improved, the dosage was reduced. However, the pain worsened in two months and he was prescribed 1500 mg of oxcarbazepine three times daily. It did not relieve the pain, which had become constant with the severity higher than 10 on a scale of 1-10. The patient was treated with LASER. Relief of neuralgia. The patient's pain level during the 1st day of treatment dropped from 10/10 to 0. On his 2nd visit. The patient continued to improve and could eat and speak without pain. This case report describes a patient who responded well by the use of LASER.
Keywords: Chronic facial pain, LASER, neural stumps, trigeminal nerve, trigeminal neuralgia, tic douloureux
|How to cite this article:|
Deenadayalan N, Kumaravel C, Narayanan A. Trigeminal neuralgia surgical treatment using LASER. J Dent Lasers 2012;6:14-6
| Introduction|| |
Trigeminal neuralgia, also known as tic douloureux, is a chronic and disabling facial pain affecting usually more than 40 years, women are slightly more affected than men, and right side is more affected. The International Association for the Study of Pain defines trigeminal neuralgia as "a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve. The pain usually lasts for a few seconds to a minute and can be like an electric shock. The pain may sometimes come in paroxysms, the frequency being variable; it is usually associated with physical triggers. The presentation is not always typical and variations may not always be easy to diagnose. Trigeminal neuralgia is severe spastic, lancinating facial pain due to a disorder of the 5th cranial nerve. Diagnosis is clinical.
| Case Report|| |
A 47-year-old DRAVADIAN Indian man presented with constant, severe pain in the right side of his face over the nasolabial groove for more than 11 months. The pain had been progressively worse and was usually precipitated by brushing his teeth, shaving, washing his face, eating, and talking. Cold water over his face made the pain worse as well as cold breeze hitting his face. The patient's neurologist treated him with 150 mg/d of carbamazepine; when the pain improved, the dosage was reduced. However, the pain worsened in two months and he was prescribed 1500 mg of oxcarbazepine three times daily. It did not relieve the pain, which had become constant with the severity higher than 10 on a scale of 1-10. The pain at times would radiate to the rest of his face. Magnetic resonance images of the brain were reported normal. Magnetic resonance of the intracranial vessels with contrast did not reveal any abnormal vascular loops or aneurismal formation.
Examination revealed an anxious healthy male in obvious pain. The pain was in the line of distribution of the maxillary division of the trigeminal nerve. The only positive finding was tenderness in the right nasolabial fold. There were no skin changes or signs of inflammation either externally or over the buccal mucosa of the right cheek; there was no evidence of infection in the gum or teeth [Figure 1].
Initially patient was given a block only with 0.5ml of normal saline to test that is it psychological. Proved negative. With that we loaded 0.4ml of local Anesthesia patient pain responded well and that conforms that is trigeminal neuralgia.
Treatment plan: Non-surgical using llt(low level laser therapy)3 or neurectomy using laser (diode 7.0 Watts)
| Materials and Methods|| |
Solid active semiconductor.
Lasing medium: Aluminum gallium and arsenide
Wave lenth: 800-980nm
Delivery system: Fibro-Optic
Mode: Continuous and gated pulse
Watts: (1.5W Inside the infra orbital cannal for 5 sec.)(2w for dissecting infra orbital nerve)(0.8w for glasing the cannal non continuous mode 5 sec).
Absorption: By pigmented tissues, water.
Since patient was not interested in LLT we planned for neurectomy using LASER after patient concern. Under LA 1:200000. Infra orbital block and psa nerve block given, High labial vestibular incision made using DIODE LASER( 2.w). Buccomuco periosteal flap raised and inferior orbital nerve identified, dissected using [Figure 2] LASER (2w) the soft tissue part avulsed by the help of artery forceps and pulled and rolled from infra orbital foramen also then fibro optic fiber was sent inside the foremen following groove [Figure 3], and hitting the fissure foot control pressed, and from backward the fiber was pulled out (1.5w). Cycle repeated once more. Finally laser glasing done [Figure 4] in the same manner (0.8w non continuous mode) was used, and the wound toileted well with saline and antiseptic solution. Sutured using 3"0" round body braided silk suture [Figure 5]. Post-operative medication: Tab. Amoxicillin-500mg bd , Tab. Metronidazole -400mg tds ,Tab.Acelofenac-200mg tds. given for 5 days.
| Results|| |
The patient's pain level during the 1st day of treatment dropped from 10/10 to 0 at the end of a 15minutes-minute treatment. Swelling was noted post operatively but no pain. Follow up of patient for one year that is every three months once. Complains of anesthesia of lateral ala of nose, infra-orbital region, and anterior gums.
| Discussion|| |
The trigeminal nerve is the largest of the cranial nerves, providing sensory input to the skin of the face and anterior half of the head, teeth. It has limited motor component to the muscles of mastication
The mechanism of pain production has been controversial. As per one theory, peripheral injury or disease of the trigeminal nerve increases afferent firing in the nerve. There may be associated failure of the central inhibitory mechanism as well. Pain is perceived when nociceptive neurons in a trigeminal nucleus involve thalamic relay neurons. Four Studies indicate that trigeminal neuralgia is usually caused by demyelination of trigeminal sensory fibers within either the nerve root or less commonly, the brainstem.  The cause of pain is explained by the ignition hypothesis. According to the hypothesis, trigeminal neuralgia results from specific abnormalities of trigeminal afferent neurons in the trigeminal root or ganglion. Injury renders the axons hyperexcitable. The hyperexcitable afferents, in turn, give rise to pain paroxysms as a result of synchronized after-discharge activity. 
Hence if it is not central lesion. It's better to do peripheral neurectomy. In peripheral neurectomy there are chances that nerve may not get avulsed properly inside the nerve canal. Leeds to neural stump which will not give a relief to the patient, hence using fibo optic tip can go deep inside the canal till fissure. So LASER is a good tool to treat trigeminal neuralgia. 
Fibro optic inside the canal may be dangerous. When it could be used in root canal which is smaller than this. Why not in infra orbital canal? Since we know the canal size ant its path using CT we can do it with fibro optic tips in mental foramen it is bent backwards enlarging the canal with bur is mandatory.
| References|| |
|1.||Love S, Coakham HB. Trigeminal neuralgia: Pathology and pathogenesis. Brain 2001;124:2347-60. |
|2.||Devor M, Amir R, Rappaport ZH. Pathophysiology of trigeminal neuralgia: The ignition hypothesis. Clin J Pain 2002;18:4-13. |
|3.||Walker JB, Akhanjee LK, Cooney MM. Laser therapy for pain of trigeminal neuralgia. Clin J Pain 1987;3:183-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]