OROFACIAL PAIN
Figure 1. Orthopantomogram shows different positions of the titanium screws that were inserted into
the incisive, infraorbital, greater palatine and mental foramens. Note the ghost image of a metal screw
in the incisive foramen area, resulting in the appearance of having two screws in the same foramen
infraorbital foramen after nerve avulsion. This
procedure relieved her pain for about a year.
During this period, pain has resurfaced on the
third division of the trigeminal nerve. She was
referred to the Universiti Hospital Kuala Lumpur
where she received 10 courses of bupivacaine
(0.5%) injection, which relieved her of neuralgia
for 6 months. In the mean time, she still continued
with her medication of carbamazepine, where she
complained of several episodes of diplopia when
the dosage was increased to 800mg/day.
She was subsequently referred to the author and
a senior consultant in 1993 for the management
of neuralgia over the distribution of the right
inferior alveolar nerve. Peripheral neurectomy of
the right inferior alveolar nerve was performed
in June, 1993. For about 6 months, she was free
from medication. However, at the end of 1993, she
reported episodes of “flick’ from her right upper
lip towards the tip of the nose. This became worse
over one month, so the author together with the
senior consultant decided to attempt cryosurgery
on her right infraorbital nerve in January, 1994.
She was pain free for 4 months but resumed to
carbamazepine medication afterward as pain
was then felt in the area supplied by the right
inferior alveolar nerve. A second neurectomy of
this nerve was performed in September 1994. The
right inferior alveolar nerve was noted to have
regenerated. Prior to that she required lignocaine
and bupivacaine injections, given at home by
her children (who are medical doctors) for postoperative pain control.
The following month, she experienced pain
in the area supplied by the greater palatine
nerve. Peripheral neurectomy of this nerve was
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performed with the patient under local anesthesia.
Subsequently, she was able to reduce the dosage
of carbamazepine to a maintenance dosage of 50
mg daily. However, in the same month, she also
complained of experiencing severe pain in the area
supplied by the maxillary incisive nerve. Peripheral
neurectomy was performed with the patient under
local anesthesia. Bone wax was place to obliterate
the incisive foramen.
Three months later, she again experienced severe
pain in the incisive area. Severe pain was also felt
in the right infraorbital area. The pain could not
be controlled even by increasing the dosage of
carbamazepine to the maximum recommended
dose. Besides, the patient could not tolerate the
side effects of high dosage of carbamazepine.
Repeat neurectomies of the right infraorbital
nerve and the incisive nerve were performed
with the patient under general anaesthesia.
The author and the senior consultants inserted
one 1.5 mm and one 2.0 mm diameter titanium
screws into the infraorbital foramen and incisive
foramen respectively. She was well postoperatively
and needed only 50 mg Carbamazepine for
maintenance.
Nine months following neurectomy, the patient
again complained of severe pain in the incisive
area. The surgical area was re-explored. Nerve
fibers were found to have re-generated and coiled
themselves around the titanium screw in the incisive
foramen. The screw was tightened following the
excision of overgrown nerve fibers. The patient
progressed well for the next 4 years following
this procedure. She has been given a low dosage
(50mg daily) of carbamazepine maintenance since,
but at the end of the fourth year, she star Y