Traumatic neuromas are rare entities which characteristically arise subsequently to surgery and are usually accompanied  by pain, typically neuralgic. We present an unusual case of an intraosseous traumatic neuroma of the inferior  alveolar nerve following tooth extraction. A 56-year-old man consulted for paresthesias and hyperesthesia in the  left mandibular region following extraction of the left mandibular third molar (#38). The panoramic radiograph  revealed a radiolucent lesion in the inferior alveolar nerve canal, and CT demonstrated the existence of a mass within  the canal, producing widening of the same. Nerve-sparing excisional biopsy was performed. Histopathology and  immunohistochemistry were consistent with traumatic neuroma of the left inferior alveolar nerve. After 3 years of  follow-up, the patient is asymptomatic and there are no signs of recurrence

Alcalá-Galiano Rubio, Andrea

Arribas-García, Ignacio

Gutiérrez, Ramón

Montalvo Moreno, J.J.

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

E186Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                           Traumatic neuroma of the mandible                                                                            Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                          Traumatic neuroma of the mandibleTraumatic neuroma of the inferior alveolar nerve: A case reportIgnacio Arribas García 1, Andrea Alcalá Galiano 2, Ramón Gutiérrez 1, Juan José Montalvo Moreno 3(1) Servicio de Cirugía Oral y Maxilofacial(2) Servicio de Radiodiagnóstico(3) Jefe de Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario 12 de Octubre. MadridCorrespondence:Dr. Ignacio Arribas-GarciaServicio de Cirugía Oral y Maxilofacial. Hospital Universitario 12 de OctubreAv Cordoba s/n  28041. Madrid. SpainEmail: ij_arribas@yahoo.esReceived: 4/05/2007Accepted: 21/10/2007Arribas-García I, Alcalá-Galiano A, Gutiérrez R, Montalvo-Moreno JJ. Traumatic neuroma of the inferior alveolar nerve: A case report. Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.© Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946http://www.medicinaoral.com/medoralfree01/v13i3/medoralv13i3p186.pdfAbstractTraumatic neuromas are rare entities which characteristically arise subsequently to surgery and are usually accompa-nied by pain, typically neuralgic. We present an unusual case of an intraosseous traumatic neuroma of the inferior alveolar nerve following tooth extraction. A 56-year-old man consulted for paresthesias and hyperesthesia in the left mandibular region following extraction of the left mandibular third molar (#38). The panoramic radiograph revealed a radiolucent lesion in the inferior alveolar nerve canal, and CT demonstrated the existence of a mass within the canal, producing widening of the same. Nerve-sparing excisional biopsy was performed. Histopathology and immunohistochemistry were consistent with traumatic neuroma of the left inferior alveolar nerve. After 3 years of follow-up, the patient is asymptomatic and there are no signs of recurrence.  Key words: Neuroma, traumatic, intraosseous, mandibular, inferior alveolar nerve, third molar.Indexed in: -Index Medicus / MEDLINE  /  PubMed            -EMBASE, Excerpta Medica-SCOPUS-Indice Médico Español                                                        -IBECS              Article Number: 10489964              © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946               eMail:  medicina@medicinaoral.com IntroductionTraumatic neuroma is a rare disorder that occurs after trauma or surgery and involves the peripheral nerves. These lesions are generally not considered to be true neoplasms (1), but represent a frustrated attempt at nerve reparation, an exaggerated response to injury consisting of reactive hy-perplasia of the nerve tissue, usually in the proximal end of a severed nerve. In the head and neck region, neuromas have been reported to occur more frequently subsequent to paro-tidectomy and neck dissection, and less so after mandibular osteotomy and tooth extraction (2-4). Common intraoral locations are the mental foramen, lower lip and tongue, but intraosseous neuromas are very uncommon. The purpose of this article is to present a rare case of intraosseous neuroma of the inferior alveolar nerve following traumatic tooth extraction and determine the diagnostic and therapeutic algorithm, providing a discussion of the clinical presenta-tion, image findings, therapeutic management and a review of the literature of these infrequent lesions.  Case ReportA 56-year-old male patient was referred by his general practitioner for hyperesthesia and paresthesias in the re-gion of the second molar of the lower left quadrant and left lower lip. The patient had past history of episodes of mild regional cellulites in the left hemimandibular region which had been successfully treated with prescribed anti-biotics and analgesics. Past surgical history was notable for surgical exodontia of an included third molar (#38) in the second decade of life. The patient accounted that the extraction was complicated and a painful postoperative period. The patient also consulted the odontologist in 3 different occasions for caries treatment in the superior molars. Physical examination was unremarkable. Hypo-anesthesia of the inferior lip and left mental region was evaluated with clinical sensory testing (tactile discrimination and thermal discrimination) which verified the subjective sensory deficiency of < 50% in the injured side in compa-Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                           Traumatic neuroma of the mandible                                                                            Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                          Traumatic neuroma of the mandibleE187Fig. 3. A. Photomicrograph showing distorted and irregularly disposed interlacing nerve fibers in a colla-genous and fibrous stroma in the traumatic neuroma. (Haematoxilin-Eosin stain. Magnification x100). B. Immunohistochemistry shows spindle shaped cells positive for both cytoplasmic and nuclear staining (S-100 protein stain. Magnification x100).Fig. 1. A. Panoramic radiograph showing a lucent lesion in the left alveolar nerve canal. Note absence of  left mandibular third molar overlying the lesion. B. Axial CT scan confirms presence of a lesion in the interior of the left inferior alveolar nerve canal. The lesion is well-defined and produces widening of the canal, without cortical disruption or expansion. C. Multiplanar oblique CT reformatted image shows expansion of the inferior alveolar nerve canal.Fig. 2. A. Intraoperative view showing exposed inferior alveolar nerve canal after tumor exeresis. B. Gross specimen of the traumatic neuroma. rison with the contralateral side. Panoramic radiograph was advised, which revealed an oval well-circumscribed, unilocular radiolucent lesion with a thin sclerotic border of about 1.5 cm in the inferior alveolar nerve canal, with widening of the same in the confluence of the left angle-ascending ramus (Fig. 1A). Computed tomography (CT) was performed demonstrating the existence of  a well-defined non-expansive oval mass of 10x15x11mm in the inferior alveolar nerve canal, causing widening of  the canal. (Figures 1B, 1C).Given the findings described, an incisional biopsy under ge-neral anesthesia was planned for histological confirmation. Nerve-sparing excision biopsy was performed via an intrao-ral approach, with vestibular incision and osteotomy of the vestibular wall of the mandible, achieving blunt dissection and exeresis of the lesion. Dissection was straightforward due to the encapsulation of the tumor, which was not adhered the nerve and had well-defined cleavage plane, characteristics that permitted its complete exeresis whilst sparing the inferior alveolar nerve (Figure 2A). E188Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                           Traumatic neuroma of the mandible                                                                            Med Oral Patol Oral Cir Bucal. 2008 Mar1;13(3):E186-8.                                                                                                                                                                          Traumatic neuroma of the mandibleNo postoperative complications occurred. Macroscopic analysis of the specimen revealed a brown rounded lesion of 1.5x0.7 cm (Figure 2B). Microscopica-lly, the lesion was composed of irregularly arranged and interlacing nerve fibers in a fibrous stroma. Immunohis-tochemistry was consistent with traumatic neuroma (Fig.ures 3A, 3B). After 3 years of  clinical and radiologic follow-up, the patient reported remission of symptoms and complete recovery of sensitivity, with absence of pain and complete recovery of sensitivity, with occasional dysesthesia. DiscussionTraumatic neuromas are very rare with only a few cases reported in the English literature (2-10). The ethiopathoge-nesis is an exaggerated response to nerve injury, in most of the cases after direct trauma or surgical manipulation, with development of reactive hyperplasia and are not considered true neoplasms in origin (11). The mechanism of damage of the inferior alveolar nerve may be due to tooth extraction, which has been reported as the most frequent etiology (1,8) or a sagittal ramus split osteotomy (2-4,10). Clinical presentation may vary. The most frequent symp-tom is pain, either neuralgic or non-neuralgic, which may be exacerbated by pressure (1). Other sensory ano-malies may appear such as paresthesias, anesthesia or hyperpathia. The cause of the neurologic symptoms is compression of the nerve by the tumor, which owing to its slow growth allows compensatory mechanisms until a threshold is reached where the nerve is compromised and the symptoms begin. At imaging, panoramic radiographs will suggest the presence of a unilocular lucent lesion embedded in the interior of the inferior dental nerve canal, which should be confirmed by CT (12). In the differential diagnosis of entities that cause hypoes-thesia or anesthesia of  the inferior alveolar nerve, we mostly have to consider malignant lesions, due to nerve compression or invasion, but these usually have a shorter natural history. The development of neurological symp-toms due to a benign process is exceptional. The radiologic differential diagnosis of unilocular lucent lesions of the mandible includes odontegenic cyst, keratocyst, central giant cell granuloma, desmoplastic ameloblastoma, fibro-mas and less likely metastasis and the malignant variants of the previously mentioned tumors (13,14).Treatment of choice is nerve-sparing surgical exeresis. An optimal technique with minimal manipulation and seve-rance of nerve fibers is essential for adequate outcome. Other second-line therapeutic options cited by different authors are stereotactic radiosurgery, local infiltration of steroids, sympathetic ganglion block, percussion, and ultrasonic therapy (1,3). Nerve sections or blockage with alcohol have proven to be ineffective and may even be detrimental (1). References1. Rasmussen OC. Painful traumatic neuromas in the oral cavity. Oral Surg Oral Med Oral Pathol. 1980 Mar;49(3):191-5. 2. Sayan NB, Uçok C. Asymptomatic traumatic neuroma after man-dibular sagittal split osteotomy: a case report. J Oral Maxillofac Surg. 2002 Jan;60(1):111-2. 3. Chau MN, Jönsson E, Lee KM. Traumatic neuroma following sagittal mandibular osteotomy. Int J Oral Maxillofac Surg. 1989 Apr;18(2):95-8. 4. Sheridan SM. Traumatic neuroma following sagittal split mandibular osteotomy. Br J Oral Surg. 1983 Sep;21(3):198-200. 5. Gregg JM. Studies of traumatic neuralgias in the maxillofacial region: surgical pathology and neural mechanisms. J Oral Maxillofac Surg. 1990 Mar;48(3):228-37. 6. Peszkowski MJ, Larsson A. Extraosseous and intraosseous oral traumatic neuromas and their association with tooth extraction. J Oral Maxillofac Surg. 1990 Sep;48(9):963-7. 7. Jimenez Burkhardt A, Martinez de Victoria JM, Bustos Ruiz V. Man-dibular intraosseous neurinoma. Apropos of a case. Rev Esp Estomatol. 1988 May-Jun;36(3):193-200. 8. Hansen HJ. Neuro-histological reactions following tooth extractions. Int J Oral Surg. 1980 Dec;9(6):411-26. 9. Lee EJ, Calcaterra TC, Zuckerbraun L. Traumatic neuromas of the head and neck. Ear Nose Throat J. 1998 Aug;77(8):670-4. 10. Kallal RH, Ritto FG, Almeida LE, Crofton DJ, Thomas GP. Trau-matic neuroma following sagittal split osteotomy of the mandible. Int J Oral Maxillofac Surg. 2007 May;36(5):453-4. 11. Batsakis JG, Regezi JA. The pathology of head and neck tumors: salivary glands, part 4. Head Neck Surg. 1979 Mar-Apr;1(4):340-9. 12. Huang LF, Weissman JL, Fan C. Traumatic neuroma after neck dissection: CT characteristics in four cases. AJNR Am J Neuroradiol. 2000 Oct;21(9):1676-80. 13. De Vicente Rodríguez JC, Junquera Gutiérrez LM, Fresno For-celledo MF, López Arranz JS. Neck schwannomas. Med Oral. 2003 Jan-Feb;8(1):71-6. 14. Penarrocha M, Sanchis JM, Orozco M. Acoustic neuroma presenting as orofacial anethesia. Med Oral. 1998 May;3(3):172-5. 

Traumatic neuroma of the inferior alveolar nerve : a case report

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