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Oral Surgery/Complete lack of sensation to touch 6 1/2 weeks after BSSRO

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QUESTION: Dear Dr. Teig,

Thank you for so generously sharing your expertise. I have read your answers pertaining to my situation back as far as 2009 and part of 2008.

I am a 61-year-old female (yes, that old) who had a BSSRO mandibular advancement on April 30th (six and and a half weeks ago). I still have profound lack of sensation to touch in my lower lip and chin, lower outer gum line, and mucosal lining. I also have altered sensations such as tightness, thinking I am dribbling even when I'm not, pain (sometimes especially in response to movement such as eating, talking, or smiling), feeling as if my lip is contorted and "fat," and stiffness. I also have great difficulty eating , and drinking is a chore. Sometimes I will realize I have been biting myself even when I am not eating. I have a bit of a speech impediment as well. Although some might find it unseemly for a 61-year-old to say this, I am devastated that I can't feel a kiss.

My surgeon appears to be very unconcerned about my symptoms I saw him a few days ago at six weeks post-op, and he said that even in a 16-year-old, feeling would just be starting to return at six weeks, and that I should relax. However, my reading of various studies and reviews of the literature leave me very worried.

My specific questions for you:

1) Is there any chance of spontaneous resolution of this problem after this much time has passed?

2) My surgeon says there was no injury to my IAN, and therefore, no need for microsurgical repair. He also said that he places the screws in such a way that there is no possibility of IAN injury from screw compression. So, in such a case, where there was no visible injury, is there anything that can be done?

3) If you do recommend seeing someone to discuss microsurgical repair, or just to discuss the implications of my situation, who would you recommend? I live in Rhode Island, but could go to New York (or Boston). In fact, I am so terrified of living with this that I have been considering going to Atlanta to see someone there who is one of the authors on some of the papers I read.

Thank you very much for your time and for sharing your knowledge.

ANSWER: Elizabeth - Let me tell you that after a bilateral sagittal split osteotomy, it is not unusual for the numbness and difficulty performing normal functions with your lips to occur.  Your surgeon should have advised you in advance that this could occur.  If it does develop it can take a few months to get better, as long as the nerve was not cut or pinched tightly during the surgery or alignment of the cut bones.  The key factor in deciding if surgery is needed to repair the nerve if no altered sensations are occurring by two months after the surgery.  Those altered sensations might involve an itching, burning or even shocks in the area.  If those sensations do occur, that is actually a good sign.  

Once of the potential problems with attempting a repair after your type of surgery, is that a complete redo or repair of the surgery will be necessary after attempting to repair the nerve.  Saying that, it is not unusual for the numbness after a BSSO, but within a few weeks, if the nerve is not damaged for the numbness to improve.  I would hate to suggest a repair without truly knowing if the nerve is actually damaged.  Before seeking a repair by a different surgeon, having the nerve fully evaluated by a neurologist, to see if even a minimal portion of the nerve is not damaged is important. You have some time.  So first either have the surgeon refer you to a neurologist or speak with your internal medicine doctor to refer you.  If after that it is determined that the nerve is damaged, then seeing a surgeon to repair the nerve is considered.  Again, opening the area to repair the nerve could damage the bone healing but it may be the only way to repair the nerve if it is damage.

Let me tell you that sometimes, damaged nerves repair themselves in time, it is not common, but it does happen occasionally.  I was not there for the surgery and I cannot predict if the situation is benign and will definitely heal if you just leave it.  

So have the nerve evaluated.  Again, call the surgeon and ask him to refer you to a neurologist to evaluate if the nerve is damaged.  I hope the area begins to itch, burn or shocks on its own as it indicates a self healing.  If you have additional questions, feel free to contact me again.



---------- FOLLOW-UP ----------

QUESTION: Dr. Teig,

My surgeon recommended a neurologist whose office said I would not be able to see him until the end of September. So I called a neurologist I had seen a few years ago for a passing leg problem, and was able to see him yesterday after having a somewhat detailed conversation with his nurse practitioner on the phone.

The neurologist told me that there is no way to evaluate the nerve electrically. The only testing he did was to run a cotton swab over the non-affected parts of my face and then over the affected area, and ask me each time if I felt anything. I learned nothing from him. He did not know which nerve had been affected, most likely the fifth, he said, and I told him that I learned from my reading that it is the inferior alveolar nerve, and indicated the open folder of medical journal articles on my lap. He said, "I don't know what you're reading, but I'll have to investigate." It was a discouraging visit.

Would you please tell me what you meant when you said I should have a neurologist evaluate the nerve to see if even a minimal portion of the nerve is not damaged? How would a neurologist do this? I don't know if I should start calling around to see if someone else can see me.

I'm thinking of calling The New York Center for Orthognathic & Maxillofacial Surgery. Do you know which doctor in this practice has the most experience with this issue? Or do you recommend someone else? I really just want to talk to someone about what is going on, and what my options are. Would they not be able to evaluate the nerve, assuming I could get a timely appointment with them?

Again, thank you for your help.
Sincerely,
Elizabeth

Answer
Elizabeth - The N Y Center for Orthognathic and Maxillofacial Surgery would be an ideal location for knowledgeable doctors in this field.  They have probably all experienced this problem is a patient and know how to examine and treat the problem, if necessary.

My suggestion is for you to make an appointment with Dr. Steve Sachs.  After seeing him, if you have any remaining questions, get back to me.  I wish you well and hope they give you a positive outlook.

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicing for over 20 years. Assistant Clincal Professor at State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA- University of Connecticut DMD-University of Pennsylvania School of Dental Medicine Oral and Maxillofacial Surgical Residency - Roosevelt Hospital, NYC

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