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Introduction 
Nomenclature 
Development 
Basic component 
Functional component 
Nucleus of trigeminal 
Ganglions of trigem...
Trigeminal pathway 
Commonest clinical applications 
Clinical implication of 
 Trigeminal ganglion 
 Opthalmic division ...
It is the 5th cranial 
nerve 
Largest cranial nerve 
It is the main 
sensory nerve of the 
face and head 
It was described...
As this nerve has 
three identical 
peripheral branches 
so that called as 
trigeminal nerve 
“Tri-Geminus” 
means thrice ...
It is derived from 1st branchial arch 
So that the structures derived from the 1st 
branchial arch are innervated by this ...
This three roots are basically sensory by nature 
Along with this sensory branch their is a motor 
root of this trigeminal...
2 Roots: 
Larger Sensory Root 
Smaller Motor Root 
3 primary divisions: 
Ophthalmic ( V1) - sensory 
- innervates the uppe...
10
Sensory nuclei 
Motor nucleus 
11
Main sensory nuclei 
Bulbospinal nuclei 
Mesenchephalic nuclei 
12
lies in pons lat to motor nucleus 
relays discriminitive touch 
13 
continuous superiorly with main 
sensory nucleus and e...
PARS ORALIS 
 associated with the 
transmission of discriminative 
(fine) tactile sense from the 
orofacial region 
PARS ...
V1 – pars caudalis 
V2- pars interpolaris 
V3- pars oralis. 
15
first order sensory 
nucleus . 
cell body of 
pseudounipolar neurons 
relay proprioception 
from muscles of 
mastication, ...
Innervates muscles 
of mastication and 
tensor tympani and 
tensor palatini 
Located in pons 
med. to princi sen. 
Nucleus...
Semilunar ganglion 
Cilliary ganglion 
Sphenopalatine ganglion 
Otic ganglion 
Submaxillary ganglion 
18
SEMILUNAR OR GASSERIAN GANGLION. 
Sensory ganglion corresponding to DRG of spinal 
nerves. 
Cresentric in shape with conve...
COVERINGS: covered by dural pouch = MECKLES CAVE 
OR CAVUM TRIGEMINALE. 
Roof- 2 layers of dura 
floor- 1 dural and 1endos...
RELATIONS: 
SUPERIORLY: sup petrosal sinus, free margin of tentorium cerebelli 
INFERIORLY: motor root , greater petrosal ...
Give off minute branches - 
tentorium cerebelli and to dura 
mater in the middle cranial 
fossa. 
From its convex border t...
Motor root runs - front and medial to the 
sensory root & passes beneath the ganglion. 
Leaves the skull - foramen ovale -...
Smallest div. 
Only sensory 
Supplies : cornea,conjuctiva,upper 
lid,forehead,ant part of scalp,nose. 
Course: 
emerges fr...
Smallest 
Passes into orbit through lat 
compartment of the sup orbital 
fissure outside the tendinous 
ring. 
Receives co...
Largest 
Enters through lat part of sup orbital fissure outside tendinous ring 
Passes forward between roof of orbit and L...
SUPRATROCHLEAR N SUPRAORBITAL N 
Smaller nerve 
Medial 
Receives commu 
branch from 
infratrochlear n 
Curves around sup m...
Sensory only 
Passes through med part of sup. 
Orbital fissure within the tendenious 
ring betwn the two div of 
occulomot...
1. Communicating branch to cilliary 
ganglion: 
passes along short cilliary nerves. 
carries symp fibres from IC plexus an...
4. INFRATROCHLEAR NERVE: 
smaller terminal branch 
emerges below trochlea 
appears on face above med angle the eye. 
suppl...
5. ANT ETHMOIDAL NERVE: 
larger terminal branch 
course: ant ethmoidal foramen and canal 
into ant cranial fossa on sup su...
CILIARY GANGLION (Lenticular ganglion) 
Situated - back part of the orbit - on the 
lateral side of the ophthalmic artery....
Second division of the trigeminal nerve. 
Is a sensory nerve. 
It begins - middle of semilunar ganglion as a flattened 
pl...
34 
Branches of Maxillary Nerve 
In the cranium Middle Meningeal Nerve 
In the Pterygopalatine 
fossa 
Zygomatic 
Sphenopa...
From middle of the gasserion ganglion it travels 
anteriorly & downwards 
Branch Within cranium –Middle meningial nerve 
R...
Zygomatic nerve 
 Lies within inferior orbital 
fissure 
 Give two branches 
Zygomaticotemporal 
 Supplies skin of temp...
Two short nerve trunk 
Unite with Pterygopalatine ganglion 
Triangular or heart-shaped, of a 
reddish-gray color. 
Situate...
Orbital 
 Periosteum of orbit 
 Post.ethmoid cells & sphenoid sinus 
 Secretory to lacrimal gland 
Nasopalatine 
Poster...
1st Trunk 
External to bone 
Buccal gingiva of maxillary molar 
2nd Trunk 
Enters into maxilla 
Sensory to maxillary sinus...
40 
MSA nerve ASA nerve 
1st & 2nd PM region supplies antarior 
wall of 
Mesiobuccal root of 1st M maxillray sinus & 
supp...
In the face (emerge through inferior orbital foramen) 
Inferior palpebral external nasal sup. Labial 
Skin of lower eyelid...
Largest 
Mixed 
Motor root- from motor sensory root- gasserian ganglion 
42 
nucleus in pons 
exit through foramen ovale i...
Trunk 
 Nervous spinosus 
 N. to med. Pterygoid 
Ant. Division 
 Massetric N. 
 Deep temporal N. 
 N. to lat. Pterygo...
Nervous spinosus 
Through foramen spinosus 
Dura mid cranial fossa 
Nerve to med. Pterygoid 
Supplies medial pterygoid 
Th...
Nerve to lat pterygoid 
Massetric nerve- lies sup to lat pterygoid,inf to 
temporalis tendon and ant to TMJ. 
supplies mas...
1.Auriculotemporal nerve- 
Arises from 2 roots which encircle the middle 
meningeal art 
The trunk passes post to lat pter...
Branches of auriculotemporal nerve 
auricular branches -supply 
tragus,upper part of aurical,roof 
of ext auditory meatus,...
2. Inferior alveolar nerve: 
Is mixed nerve 
Passes between mandible and sphenomandibular lig inf 
to lat pterygoid, 
Ente...
3.Lingual nerve: lies ant to inf. alveolar n between lat 
pterygoid and tensor palatini 
receives chorda tympani (SVA) 
Em...
Branches of lingual nerve and its 
communications: 
1.Chorda tympani 
2.Communications with 
submandibular ganglion 
3.Hyp...
Submandibular/ Submaxillary 
ganglion 
Otic ganglion 
51
SUBMAXILLARY / SUBMANDIBULAR 
GANGLION: 
Small size & fusiform in shape. 
Situated above the deep portion of the 
submaxil...
OTIC GANGLION: 
Small, oval shaped,reddish-gray color ganglion 
- situated immediately below the foramen ovale. 
Lies - me...
Responsible for carrying 
Pain ,Temperature 
Light Touch 
discriminative touch 
pressure 
Utilize the 3-neuron sensory sys...
55
56
 The most commonly anesthetized nerves in dentistry 
are branches or nerve trunks associated with the 
maxillary and mand...
Techniques of Maxillary Regional 
Anesthesia 
The techniques most commonly employed in maxillary 
anesthesia include 
• Su...
59
60
Inferior alveolar nerve block 
Lingual nerve block 
Mental nerve block 
PDL infiltration 
Local infiltration (occasionally...
62
Shingles and varicella-zoster: The trigeminal 
ganglion, as any sensory ganglion, may be the site 
of infection by the her...
Ethmoid tumours 
Malignant tumours of the mucous lining of the 
ethmoid air cells may expand into the orbits, 
damaging br...
Corneal reflex: When the cornea is touched, usually 
with a wisp of cotton, the subject blinks. This tests 
V and VII. The...
Infraorbital injuries (malar fractures): 
Trauma to infraorbital margin may cause sensory loss 
of infraorbital skin. 
Max...
Maxillary sinus infections: Infections of the 
maxillary sinus may cause infraorbital pain or may 
cause referred pain to ...
Lingual nerve: Careless 
extractions of the third 
lower molar, abscesses of 
its root, or fractures of 
the angle of the ...
Inferior alveolar nerve: Trauma to the 
mandible may damage or tear 
the inferior alveolar nerve in the 
mandibular canal ...
Mumps: Mumps is inflammation of the parotid 
gland causing tension in the parotid capsule which 
is innervated by the auri...
Referred pain to the ear: Disease of the TMJ or 
swelling of the parotid gland may cause ear ache 
because of referred pai...
Infections and neoplasia most commonly involve 
the peripheral divisions of the trigeminal nerve 
rather than the intracra...
Pituitary fossa and cavernous sinus lesions may 
extend to the Meckel’s cavity or involve the 
cavernous portion of the tr...
Multiple sclerosis, glioma, and infarction are the 
most common brainstem and upper cervical cord 
lesions resulting in fi...
Consists of flushing and 
sweating of the ipsilateral 
face in the distribution of 
the auriculotemporal nerve 
upon eatin...
It is also known as the Reader 
Syndrome and is a rare 
disorder produced by tumors 
arising in the semilunar 
ganglion. 
...
In conclusion, a variety of conditions may involve 
the different segments of the trigeminal nerve. 
Knowledge of its anat...
Monhem’s Local Anaesthesia 
and Pain Controll in Dental 
Practice; C.Richard Bennett, 
7th Edition; CBS publication 
Crani...
79
Trigeminal nerve and its importance in max-fac surgery
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Trigeminal nerve and its importance in max-fac surgery

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short description on fifth cranial nerve with its importance

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Trigeminal nerve and its importance in max-fac surgery

  1. 1. 1
  2. 2. Introduction Nomenclature Development Basic component Functional component Nucleus of trigeminal Ganglions of trigeminal Trigeminal ganglion Divisions of trigeminal nv  Opthalmic branch  Ciliary ganglion  Maxillary branch & associated ganglion  Mandibular branch & associated ganglion 3
  3. 3. Trigeminal pathway Commonest clinical applications Clinical implication of  Trigeminal ganglion  Opthalmic division  Maxillary division  Mandibular division Lesion associated with intracranial part of trigeminal nerve Frey’s syndrome Paratrigeminal syndrome conclusion 4
  4. 4. It is the 5th cranial nerve Largest cranial nerve It is the main sensory nerve of the face and head It was described by Fallopius & Meckle in 1748 5
  5. 5. As this nerve has three identical peripheral branches so that called as trigeminal nerve “Tri-Geminus” means thrice twinned This term is coined by Winslow. 6
  6. 6. It is derived from 1st branchial arch So that the structures derived from the 1st branchial arch are innervated by this nerve. The trigeminal nerve contains both sensory and motor components. The somata of, motor neuroblasts originate with in neuroepithelium, sensory neuroblasts --- derived from the neural crest and from ectodermal placodes. 7
  7. 7. This three roots are basically sensory by nature Along with this sensory branch their is a motor root of this trigeminal nerve It is mixed nerve. Contains 170,000 sensory fibres 7,700 motor fibres The 3 divisions have approx ophthalmic 26,000 maxillary 50,000 mandibular 78,000 8
  8. 8. 2 Roots: Larger Sensory Root Smaller Motor Root 3 primary divisions: Ophthalmic ( V1) - sensory - innervates the upper portion of the face Maxillary (V2)- sensory – innervates the mid face region Mandibular (V3) -sensory+motor – innervates the lower facial region 9
  9. 9. 10
  10. 10. Sensory nuclei Motor nucleus 11
  11. 11. Main sensory nuclei Bulbospinal nuclei Mesenchephalic nuclei 12
  12. 12. lies in pons lat to motor nucleus relays discriminitive touch 13 continuous superiorly with main sensory nucleus and extends inferiorly through medulla oblongata and into upper part of spinal cord as far as second cervical segment. where its continuous with sub.Gelatinosa.
  13. 13. PARS ORALIS  associated with the transmission of discriminative (fine) tactile sense from the orofacial region PARS INTERPOLARIS  associated with the transmission of tactile sense, as well as dental pain PARS CAUDALIS  associated with the transmission of nociception and thermal sensations from the head 14
  14. 14. V1 – pars caudalis V2- pars interpolaris V3- pars oralis. 15
  15. 15. first order sensory nucleus . cell body of pseudounipolar neurons relay proprioception from muscles of mastication, facial muscles. forms monosynaptic reflex arc . situated in midbrain just lat to aqueduct 16
  16. 16. Innervates muscles of mastication and tensor tympani and tensor palatini Located in pons med. to princi sen. Nucleus 17
  17. 17. Semilunar ganglion Cilliary ganglion Sphenopalatine ganglion Otic ganglion Submaxillary ganglion 18
  18. 18. SEMILUNAR OR GASSERIAN GANGLION. Sensory ganglion corresponding to DRG of spinal nerves. Cresentric in shape with convexity anterolat. Contains cell bodies of pseudounipolar neurons. LOCATION: lies in a bony fossa at apex of the petrous temporal bone on floor of middle cranial fossa , just lat to post. Part of lat wall of the cavernous sinus. 5 cm deep to the preauricular point 19
  19. 19. COVERINGS: covered by dural pouch = MECKLES CAVE OR CAVUM TRIGEMINALE. Roof- 2 layers of dura floor- 1 dural and 1endosteal dural layer. cave lined by pia and arachnoid thus the ganglion is bathed in CSF. ARTERIAL SUPPLY: ganglionic branches of ICA, middle meningeal artery and accessory meningeal artery. 20
  20. 20. RELATIONS: SUPERIORLY: sup petrosal sinus, free margin of tentorium cerebelli INFERIORLY: motor root , greater petrosal nerve, petrous apex foramen lacerum MEDIALLY: post. Part of lat. Wall of cavernous sinus ICA with its sympathetic plexus LATERALLY: uncus of temporal lobe nervous spinosum. 21
  21. 21. Give off minute branches - tentorium cerebelli and to dura mater in the middle cranial fossa. From its convex border three large nerves arises Ophthalmic Maxillary Mandibular. Ophthalmic and Maxillary - exclusively of sensory fibers. Mandibular is joined outside the cranium by the motor root. 22
  22. 22. Motor root runs - front and medial to the sensory root & passes beneath the ganglion. Leaves the skull - foramen ovale - immediately below this foramen - joins the mandibular nerve 23
  23. 23. Smallest div. Only sensory Supplies : cornea,conjuctiva,upper lid,forehead,ant part of scalp,nose. Course: emerges from trigeminal ganglion lat wall cavernous sinus 3 branches in ant part of cavernous sinus nasocilliary, frontal, lacrimal superior orbital fissure orbit 24
  24. 24. Smallest Passes into orbit through lat compartment of the sup orbital fissure outside the tendinous ring. Receives communicating branch from trochlear nerve Receives branch from zygomaticotemporal nerve Passes along sup border of LR with lacrimal art Sensory to lat conjunctiva,UL, lacrimal gland(parasym secretomotor). 25
  25. 25. Largest Enters through lat part of sup orbital fissure outside tendinous ring Passes forward between roof of orbit and LPS Divides midway into SUPRATROCHLEAR NERVE SUPRAORBITAL NERVE 26
  26. 26. SUPRATROCHLEAR N SUPRAORBITAL N Smaller nerve Medial Receives commu branch from infratrochlear n Curves around sup med margin of orbit supplies: med conjunctiva and UL lower part of forehead Lies betwn frontalis and corrugator supercilli Larger Lies lateral Passes through supraorbital notch Lies beneath frontalis Divides in med and lat branches. Supplies: conjunctiva, scalp upto vertex, mucous membrane of frontal sinus 27
  27. 27. Sensory only Passes through med part of sup. Orbital fissure within the tendenious ring betwn the two div of occulomotor nerve. Crosses from lat to med above Optic Nerve with ophthalmic art Runs along med wall of orbit betwn SO and MR Divides into terminal branches ANT ETHMOIDAL NERVE and INFRATROCHLEAR NERVE 5 branches in orbit. 28
  28. 28. 1. Communicating branch to cilliary ganglion: passes along short cilliary nerves. carries symp fibres from IC plexus and sensory fibres from the eyeball. 2. LONG CILLIARY NERVES : 2 or 3. run along med side of the ON pierce sclera and supply cornea, iris, cilliary body. carry pain temp and touch. sympathetic motor supply to dilator pupillae. 3. POST ETHMOIDAL NERVE: passes thru post ethmoidal foramen to supply the ethmoid and sphenoid PNS. 29
  29. 29. 4. INFRATROCHLEAR NERVE: smaller terminal branch emerges below trochlea appears on face above med angle the eye. supplies: upper half of external nose skin of med most part of UL andLL medial conjunctiva lacrimal sac caruncle 30
  30. 30. 5. ANT ETHMOIDAL NERVE: larger terminal branch course: ant ethmoidal foramen and canal into ant cranial fossa on sup surf of cribriform plate Through slit lat to crista galli into nasal cavity Med internal nasal branch lat internal nasal branch Supplies ant nasal septum supplies ant part lat nasal cavity emerges as external nasal nerve to skin of ala,vestibule,and tip of nose 31
  31. 31. CILIARY GANGLION (Lenticular ganglion) Situated - back part of the orbit - on the lateral side of the ophthalmic artery. Its roots are 3 in number and enter its posterior border. Long or Sensory Root (sympathetic root) -Derived from the nasociliary nerve. -carries postganglionic fiber from sup.cervical sympathetic ganglion - innervate radial fiber of dilator pupillae muscle in iris Short or Motor Root (parasympathetic root) - Derived from the branch of the oculomotor nerve - these preganglionic fiber along with the post ganglionic fiber form short ciliary nerve which innervate sphinctre pupillae & ciliary muscle of iris Sympathetic Root - fsensory root of nasocilliary nerve - it causes pupil to dilate - it causes pupil to constrict - changes the convexity of lense 32
  32. 32. Second division of the trigeminal nerve. Is a sensory nerve. It begins - middle of semilunar ganglion as a flattened plexiform band, passing horizontally forward - leaves the skull , foramen rotundum. Then crosses - pterygopalatine fossa - enters the orbit through the inferior orbital fissure - it traverses the infraorbital groove and canal in the floor of the orbit and appears on the face - infraorbital foramen 33
  33. 33. 34 Branches of Maxillary Nerve In the cranium Middle Meningeal Nerve In the Pterygopalatine fossa Zygomatic Sphenopalatine Posterior Superior Alveolar In the Infraorbital Canal Anterior Superior Alveolar Middle Superior Alveolar On the Face Inferior Palpebral External Nasal Superior Labial
  34. 34. From middle of the gasserion ganglion it travels anteriorly & downwards Branch Within cranium –Middle meningial nerve Run along with middle meningial artery, -- sensory innervation to dura matter. Exit cranium from foramen rotundum 35
  35. 35. Zygomatic nerve  Lies within inferior orbital fissure  Give two branches Zygomaticotemporal  Supplies skin of temporal region after peircing temporal fascia 2 cm above zygoma  Gives communicating branch to lacrimal N suppling parasymp. Secretomotor fibres to lacrimal gland Zygomaticofacial  Supply skin of face 36
  36. 36. Two short nerve trunk Unite with Pterygopalatine ganglion Triangular or heart-shaped, of a reddish-gray color. Situated just below the maxillary nerve as it crosses the fossa. It receives a sensory, a motor, and a sympathetic root. Redistribute in 4 branches Orbital Nasal/ nasopalatine Palatine Pharyngeal 37
  37. 37. Orbital  Periosteum of orbit  Post.ethmoid cells & sphenoid sinus  Secretory to lacrimal gland Nasopalatine Posterior superior lateral nasal branch  Carry sensation from mucous memb.of nasal septum & post.ethmoid cells Medial/septal branch  Mucous membrane on vomer Nasopalatine  Come out through incisal canal & supply premaxilla Palatine Greater/Anterior palatine  Emerge from greater palatine foramen  Carries secretory & sensory fibers to mucous of hard palate & palatal gingivae Middle palatine  Emerge from small foramen of pyramidal part of palatine bone  Supply sensory & secretory fibers to soft palate Posterior/ Lesser palatine  Emerge from lesser palatine foramen  Supply sensory and secretory fibers to tonsillar area Pharyngeal Sensory and secretory fibers to nasopharynx 38
  38. 38. 1st Trunk External to bone Buccal gingiva of maxillary molar 2nd Trunk Enters into maxilla Sensory to maxillary sinus, maxillary molar (except mesio buccal root of 1st max.molar) 39
  39. 39. 40 MSA nerve ASA nerve 1st & 2nd PM region supplies antarior wall of Mesiobuccal root of 1st M maxillray sinus & supplies 1 to 3. PDL, buccal soft tissue, bone (in 30% cases, it is absent then Psa & Asa Provides its supplies).
  40. 40. In the face (emerge through inferior orbital foramen) Inferior palpebral external nasal sup. Labial Skin of lower eyelid skin of lateral skin,mucous aspect of nose memb.,upper 41 lip.
  41. 41. Largest Mixed Motor root- from motor sensory root- gasserian ganglion 42 nucleus in pons exit through foramen ovale in grt. Wing of sphenoid from trunk in infra-temporal fossa travels between lat. Pterygoid and otic ganglion laterally and tensor palatine medially anteriorly to med. Meningeal A. small ant. Division large post. division
  42. 42. Trunk  Nervous spinosus  N. to med. Pterygoid Ant. Division  Massetric N.  Deep temporal N.  N. to lat. Pterygoid  Buccal N. Post. Division  Auriculo temporal  Inf. Alveolar  Lingual N. 43
  43. 43. Nervous spinosus Through foramen spinosus Dura mid cranial fossa Nerve to med. Pterygoid Supplies medial pterygoid Through otic ganglion without interruption to Tensor tympani Tensor palatini 44
  44. 44. Nerve to lat pterygoid Massetric nerve- lies sup to lat pterygoid,inf to temporalis tendon and ant to TMJ. supplies masseter and TMJ Buccal nerve-is the only sensory branch of ant div. travels betwn 2 heads of lat pterygoidand emerges in cheek at ant border of masseter. Supplies skin and mm of cheek. Deep temporal nerve -the 2 nerves ascend deep to lat pterygoid and supply temporalis. 45
  45. 45. 1.Auriculotemporal nerve- Arises from 2 roots which encircle the middle meningeal art The trunk passes post to lat pterygoid betwn neck of mandible and sphenomandibular lig sup to 1st part of maxillary art. Lies behind the TMJ close to the parotid Ascends behind sup temporal vessels and then in temporal region divides into superficial temporal branches. 46
  46. 46. Branches of auriculotemporal nerve auricular branches -supply tragus,upper part of aurical,roof of ext auditory meatus,anterosup part of tympanic memb Superficial temporal branches-supply skin of temple Articular branches-supply the TMJ. 47
  47. 47. 2. Inferior alveolar nerve: Is mixed nerve Passes between mandible and sphenomandibular lig inf to lat pterygoid, Enters mandible through mandibular foramen to run in a bony canal below the teeth Branches: to molars and premolars incisive nerve mental nerve mylohyoid nerve-mylohyoid and ant belly of diagastric communicating nerve to lingual nerve 48
  48. 48. 3.Lingual nerve: lies ant to inf. alveolar n between lat pterygoid and tensor palatini receives chorda tympani (SVA) Emerges from inf border of lat pterygoid to lie betwn ramus and med pterygoid Between origins of sup constrictir and mylohyoid 1 cm below and behind 3rd molar in gingiva Rests on hypoglossus lat to the tongue where it is related to the submandibular ganglion Gives sensory supply to presulcal tongue ,floor of mouth, mandibular gums,and carries proprioception from tongue. 49
  49. 49. Branches of lingual nerve and its communications: 1.Chorda tympani 2.Communications with submandibular ganglion 3.Hypoglossal nerve 50
  50. 50. Submandibular/ Submaxillary ganglion Otic ganglion 51
  51. 51. SUBMAXILLARY / SUBMANDIBULAR GANGLION: Small size & fusiform in shape. Situated above the deep portion of the submaxillary / Submandibular gland. DISTRIBUTION: Arise - from the lower part of the ganglion. Supply - mucous membrane of the mouth and the duct of the submaxillary gland. 52
  52. 52. OTIC GANGLION: Small, oval shaped,reddish-gray color ganglion - situated immediately below the foramen ovale. Lies - medial surface of the mandibular nerve. DISTRIBUTION: A filament to the Tensor tympani. Tensor veli palatini. 53
  53. 53. Responsible for carrying Pain ,Temperature Light Touch discriminative touch pressure Utilize the 3-neuron sensory system Primary neuron secondary neuron tertiary neuron Utilize the contra lateral ventral trigeminothalamic tract 54
  54. 54. 55
  55. 55. 56
  56. 56.  The most commonly anesthetized nerves in dentistry are branches or nerve trunks associated with the maxillary and mandibular divisions of the trigeminal nerve.  The maxilla’s relatively porous alveolar bone allows for the use of straightforward local anesthetic techniques of paraperiosteal field blocks or infiltrations.  The mandible is different. The outer layer of cortical bone is thick and nonporous and thus normally requires the use of a nerve block at a site away from the teeth being treated. 57
  57. 57. Techniques of Maxillary Regional Anesthesia The techniques most commonly employed in maxillary anesthesia include • Supraperiosteal (local) infiltration • Periodontal ligament (intraligamentary) injection • Posterior superior alveolar nerve block • Middle superior alveolar nerve block • Anterior superior alveolar nerve block • Greater palatine nerve block • Nasopalatine nerve block • Local infiltration of the palate • Intrapulpal injection 58
  58. 58. 59
  59. 59. 60
  60. 60. Inferior alveolar nerve block Lingual nerve block Mental nerve block PDL infiltration Local infiltration (occasionally) 61
  61. 61. 62
  62. 62. Shingles and varicella-zoster: The trigeminal ganglion, as any sensory ganglion, may be the site of infection by the herpes zoster virus causing shingles, a painful vesicular eruption in the sensory distribution of the nerve. Trigeminal neuralgia (tic douloureux): This is severe pain in the distribution of the trigeminal nerve or one of its branches, the cause often being unknown. It may require partial destruction of the ganglion. 63
  63. 63. Ethmoid tumours Malignant tumours of the mucous lining of the ethmoid air cells may expand into the orbits, damaging branches of opthalmic nerve. This may lead to displacement of the orbital contents causing proptosis and squint, and sensory loss over the anterior nasal skin. Nasal fractures Trauma to the nose may damage the nasociliary nerve. Sensory loss of the skin down to the tip of the nose may result. 64
  64. 64. Corneal reflex: When the cornea is touched, usually with a wisp of cotton, the subject blinks. This tests V and VII. The nerve impulses pass through cornea and then through nasociliary nerve to the brain. Supraorbital injuries Trauma to the supraorbital margin may damage the supraorbital and supratrochlear nerves causing sensory loss in the scalp. 65
  65. 65. Infraorbital injuries (malar fractures): Trauma to infraorbital margin may cause sensory loss of infraorbital skin. Maxillary antrum tumours: Malignant tumors of the mucous lining of the maxillary antrum may expand into the orbit, damaging branches of maxillary nerve, particularly the infraorbital. This may lead to anaesthesia over the facial skin. 66
  66. 66. Maxillary sinus infections: Infections of the maxillary sinus may cause infraorbital pain or may cause referred pain to other structures supplied by maxillary nerve e.g. upper teeth. Maxillary teeth abscesses: The roots of the maxillary teeth (especially the second molars) are intimately related to the maxillary sinus. Root abscesses are painful. 67
  67. 67. Lingual nerve: Careless extractions of the third lower molar, abscesses of its root, or fractures of the angle of the mandible may all damage the lingual nerve. This may result in loss of somatic sensation from the anterior portion of the tongue and loss of taste sensation. Protection of lingual nerve:: during surgical removal of mandibular third molar- 68
  68. 68. Inferior alveolar nerve: Trauma to the mandible may damage or tear the inferior alveolar nerve in the mandibular canal leading to sensory loss distal to the lesion. 69
  69. 69. Mumps: Mumps is inflammation of the parotid gland causing tension in the parotid capsule which is innervated by the auriculotemporal nerve. It gives both local tenderness and referred ear ache. Submandibular duct: The intimate relationship between the submandibular duct and the lingual nerve is significant in duct infections and surgery. If the lingual nerve were damaged during a submandibular surgery, there would be sensory loss, both somatic and taste, in the anterior portion of the tongue. 70
  70. 70. Referred pain to the ear: Disease of the TMJ or swelling of the parotid gland may cause ear ache because of referred pain. Also, pain from the lower teeth, oral cavity and tongue may be referred to the ear. Superficial temporal artery biopsy: The auriculotemporal nerve accompanies the superficial temporal artery on the temple. In cases of temporal arteritis, the nerve is anaesthetized so that the overlying skin can be incised to obtain a biopsy of the artery. 71
  71. 71. Infections and neoplasia most commonly involve the peripheral divisions of the trigeminal nerve rather than the intracranial part. The Meckel’s cavity can be involved either by extrinsic or intrinsic disease. Extrinsic lesions, usually bony metastasis, chordoma, or chondrosarcoma, destroy adjacent bone as they extend toward the Meckel’s cavity. Intrinsic lesions simply expand the Meckel’s cavity. 72
  72. 72. Pituitary fossa and cavernous sinus lesions may extend to the Meckel’s cavity or involve the cavernous portion of the trigeminal nerve divisions as well. The trigeminal nerve has three sensory and one motor nuclei. The sensory nuclei are the principal, mesencephalic, and spinal sensory. The cervical extension of the spinal sensory nucleus explains the relation of upper cervical disk herniation and its association with trigeminal sensory neuropathy. 73
  73. 73. Multiple sclerosis, glioma, and infarction are the most common brainstem and upper cervical cord lesions resulting in fifth cranial nerve symptom. Less common lesions include metastasis, cavernous hemangiomas, hemorrhage, and arteriovenous malformation. Rarely, rhombencephalitis may develop as a result of retrograde extension of herpes simplex virus type 1 from the trigeminal ganglion into the brainstem. 74
  74. 74. Consists of flushing and sweating of the ipsilateral face in the distribution of the auriculotemporal nerve upon eating or tasting. It is occasionally seen following injury or infection of the parotid gland area . 75
  75. 75. It is also known as the Reader Syndrome and is a rare disorder produced by tumors arising in the semilunar ganglion. Characterised by trigeminal neuralgia at the onest , followed by facial anesthesias on the affected side. The muscles of mastication are found weakened or paralysed. 76
  76. 76. In conclusion, a variety of conditions may involve the different segments of the trigeminal nerve. Knowledge of its anatomic course and its application allows an understanding of disorders involving the brainstem, the nerve parts and adjacent skull base. 77
  77. 77. Monhem’s Local Anaesthesia and Pain Controll in Dental Practice; C.Richard Bennett, 7th Edition; CBS publication Cranial Nerves Functional Anatomy, Stanley Monkhouse;2nd edition 2006; Cambridge university press. Sicher and DuBRULS ORAL ANATOMY by E. LLOYOD DuBRUL, 8th Edition,Ishiyaku EuroAmerica, Inc. Publishers Gray’s anatomy, Henry Gray; 40th edition 78
  78. 78. 79

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