THIS SLIDE WILL HELP BOTHE MEDICAL AND DENTAL GUYS.

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PANKAJ KUMAR
BDS FINAL YEAR
ORAL AND MAXILOFACIAL SURGERY

2. CONTENTS
Introduction
Definition
Classification
Etiology and Pathogenesis
Clinical features
Diagnosis
Treatment and management
Public Health Importance
Conclusion
References

3. INTRODUCTION
Anatomy of Trigeminal nerve

6. DEFINITION
• Sudden, usually
unilateral, severe brief
stabbing pain in the
distribution of one of
more branches of the
V nerve.

7. Other names
Tic douloureux – Nicholaus Andre
Fothergill’s disease – John Fothergill

8. CLASSIFICATION:
International Headache Society (IHS) classified
trigeminal neuralgia into two types:
Classical /idiopathic/typical
Symptomatic

9. Classical trigeminal
neuralgia is a unilateral
disorder characterized
by brief electric, shock-
like pains.
are abrupt in
and termination
They
onset
and limited to the
distribution of one or
more divisions of the
trigeminal nerve.

10. Symptomatic trigeminal neuralgia
Pain is similar to classical type
But it is
structural
caused
lesion
by a
other
demonstrable
than vascular
compression.

11. ETIOLOGY
Compression of the trigeminal nerve root
Primary demyelination disorders
Multiple sclerosis
Charcot-Marie-Tooth disease(hereditary
sensory motor neuropathy)
Infiltrative disorders of the trigeminal nerve
root, ganglion and nerve
Carcinomatous deposits
Perineural spread of head and neck cancer
Non-demyelinating lesions of the pons or
medulla
Familial trigeminal neuralgia

12. Compression of the Trigeminal Nerve Root

14. Compressive lesions
Tumor of cerebellar pontine angle
Posterior cranial fossa tumors
Schwannomas
Meningioma
Epidermoid cyst
deformity
imperfecta
Compression from osteoma or
resulting from osteogenesis
(rarely)

16. PATHOGENESIS
Superior cerebellar artery pressing on or
grooving the root of the nerve causes pressure
which results in
focal demyelinization and hyperexcitability of
nerve fibres
which fire in response to light touch resulting in
brief episodes of intense pain.

17. CLINICAL FEATURES
Rare
Middle age
Female predilection (60%)
Maxillary division more commonly involved
Opthalmic division rarely involved
Shaving, showering, speaking, eating, or
exposure to wind triggers episodes
Contd…….

18. CLINICAL FEATURES……………….
Pain occurs in areas of the face where the
trigeminal nerve supplies normal sensation:
cheek, jaw, teeth, gums and lips, and
sometimes the eye or forehead
The pain is described as episodes of
–stabbing, electric
intense feeling like
shocks, burning, crushing, exploding,
lancenating pain

19. Pain lasts for few
seconds to minutes
Unilateral
(predominantly right
side)
Precipitated by trigger
zones
Extreme cases ‘frozen
or mask like face’

20. Trigger zones

22. DIAGNOSIS
 History
 Clinical examination
 Diagnostic LAblocks
 CT scan
 MRI

23. Pain History
 Chief complaint
 History of present illness
 Current symptoms: Onset, Location, Quality,
Intensity, Frequency, Duration
 Aggravating and alleviating factors
 Past treatments

24. IHS diagnostic criteria for trigeminal
neuralgia
Classic trigeminal neuralgia
A. Paroxysmal attacks of facial or frontal pain
that last a few seconds to less than 2 minutes,
affecting one or more divisions of the
trigeminal nerve and fulfilling criteria B and
C.

25. B. Pain has at least one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2.Precipitated from trigger areas or by
trigger factors
3.The patient is entirely asymptomatic
between paroxysms.

26. are stereotyped in the individual
no clinically evident neurological
C. Attacks
patient.
D. There is
deficit.
E. Not attributed to another disorder.

27. Symptomatic trigeminal neuralgia
A. Paroxysmal attacks of pain lasting from a
fraction of a second to 2 minutes, with or
without persistence of aching between
paroxysms, affecting one or more divisions of
the trigeminal nerve and fulfilling criteria B.

28. B. Pain has at least one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2.Precipitated from trigger areas orby trigger
factors
3.Attacks are stereotyped in the individual
patient
4. A causative lesion, other than vascular
compression, has been demonstrated by
special investigations and/or posterior fossa
exploration.

29. Differential Diagnosis Of Classic
Trigeminal Neuralgia
1. Secondary trigeminal neuralgia
2. Pain of dental origin
3. Extracranial
4. Neuropathic
5. Neurovascular
6. Psychogenic

30. TREATMENT
Medical management
Surgical management

31. Treatment of trigeminal neuralgia is broadly
divided into two categories:
1. Destructive treatment:
 Radiofrequency Rhizotomies
 Balloon Gangliolysis
 Stereotactic Radiosurgery (ie Gamma Knife)
The possible complication of destructive
treatment is facial numbness, neuroparalytic
keratitis, or the sever complication of anesthesia
dolorosa which is a more complex facial pain.

32. 2. Non destructive treatment:
 Medical treatment (Tegretol, Baclofen,
Dilantin, etc.)
 Microvascular decompression (with initial
success rate of 85 to 95%)
The possible complication of non destructive
treatment is side effect of medication and risk of
surgery.

33. Medical management
CARBAMAZEPINE
100– 200mg, bd ortid
Which provides benefit to more than 75% of
patients
Common trade names: Tegretol, Tegretol XL,
Carbitrol
Mode of action
Side effects

34. Other Medication
 Oxcarbazepine
 Gabapentin
 Lamotrigine
 Baclofen
 Topiramate
 Sodium valproate
 Phenytoin
 Clonazepam
 Felbamate
 Pimozide
 Zonisamide
 Pregabalin

35. Surgical management
Surgical options have been reserved for those
patients
who have a clearly defined secondary cause
for the trigeminal neuralgia,
who are unresponsive,
who have severe, unremitting pain that
limits their ability to eat,
for whom multiple medications are
intolerable or contraindicated

36. Surgical options
Percutaneous glycerol rhizolysis
Percutaneous balloon compression
Radiofrequency trigeminal (retrogasserian)
rhizotomy
Gamma knife radiosurgery
Microvascular decompression

38. Percutaneous Glycerol Rhizolysis
This procedure is used in
Arterial or venous compression of the
trigeminal nerve
Multiple sclerosis
Done with absolute alcohol or
phenol/glycerol mixture injected
phenol or
into the
trigeminal cistern

39. Hartel technique
When the needle pierces the foramen ovale and enters
the trigeminal cistern there is usually a characteristic
jaw twitch and CSF returns through the needle.
Lack of CSF return may be related to poor position of
the needle or to scarring within the cistern due to prior
surgery

40. Glycerol rhizolysis (GR)
Test dose: 0.1-0.15 ml
0.05~0.1 ml at 3~5 min. intervals
Total dose: 0.1~0.4 ml
Sensory changes: pain, burning or
paresthesia

41. Percutaneous balloon compression
0.5 - 1ml of contrast
Pear-shape balloon
Compression time: 1-7
min.

43. Radiofrequency thermo-coagulation
 The theory behind the use of radiofrequency to
lesion the trigeminal nerve is that it may
selectively injures/destroys the unmyelinated
or poorly myelinated nociceptive nerve fibers
and spares the (heavily) myelinated fibers
which serve touch, proprioception, and motor
function

44. Apermanent lesion in the retrogasserian trigemianal
nerve is made by beginning at 10Vand approximately
60mAfor a duration of 30-40 sec and increasing to
approx. 20Vand 100mA

46. (a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode
(c) Expansion of thermal energy to neighboring neural structures.

48. Gamma knife radiosurgery

49.  The Gamma
focused array
intercepting beams
Knife is a
of
201
of
gamma radiation, produced
by separate cobalt sources.
 The dose is 70–90Gy.
 Pain relief is usually not
immediate.
 The mean time to pain relief
in two series was
approximately one month.

50. Microvascular decompression
It is the only medical or surgical intervention
that directly addresses the presumed
underlying pathology of classic trigeminal
neuralgia.
Retrosigmoid craniectomy approach

51. Operative approach

54. Microvascular decompression(MVD)

55. RFL for patients who are elderly or medically
frail.
Posterior fossa exploration and MVD for
younger healthier patients who can tolerate the
longer more invasive surgical procedure.
GKR as an alternative to RFL in frail or elderly
patients. MVD or RFL remains the standard
for surgical treatment of younger patients who
have considerable life expectancy

56. Peripheral procedures
Peripheral
neurectomies
Cryotherapy
(cryonanlgesia)
Alcohol block
Streptomycin –
lidocaine injections

57. OMFS….
Peripheral neurectomy
Supra orbital
Infra orbital
Mental
Inferior alveolar
Long buccal
Lingual (rarely)

58. Infraorbital neurectomy

59. SUPRAORBITAL NEURECTOMY

60. Inferior Alveolar Nerve
Neurectomy

61. Trigeminal Neuralgia Diet
Low fat, high protein, high calorie
Easy chewable foods
Served lukewarm
Offered frequently
Trigeminal Neuralgia Association recommends
 avoidance of: extreme hot/cold, hot sauce,
chili, spicy salsa, mints, black pepper,
cinnamon, ginger, nutmeg

62. PUBLIC HEALTH IMPORTANCE
 Trigeminal neuralgia has an incidence of 4–5
per 100,000 of the
population.
 It is nearly twice as common in women,
 Incidence increases in age to around 1 in
1000 patients older than 75 years of
age.
 Rarely,familial cases have been reported.
 It is reported that 150,000 people are
diagnosed with trigeminal neuralgia every
year.

63.  The only indication about the prevalence of
TN comes from a study by Penman , who in
1969 reported rates of 107.5/1000000 in men
and 200.2/1000000 in women.
 TN is therefore a raredisease
 TN incidence progressively increases with
increasing age: from 17.5/100000/ between 60
and 69 years of age up to 25.6/100000/year
after 70.

64.  The female-to-male ratio was 1.74:1 in the
Katusic et al. study
 and 3:2 in another study by Ashkenazi and
Levin.

65. CONCLUSION
Population-based epidemiological studies
are essential to determine the spectrum of
TN symptoms in the population,
identifying individuals in whom symptoms
are mild enough that they do not seek
treatment. Potentially useful approaches in
studying the epidemiology of TN include
multi-site population-based studies

66. A concerted program of epidemiologic
to identify these key
studies is needed
features of TN: prevalence and public
health impact, especially among women
and members of minority groups; risk
factors; comorbidity; prodromal symptoms;
and natural history.

67. REFERENCES:
Fonseca, Marciani, Turvey, Oral and
Maxillofacial surgery, 2nd edition, volumeII
,Saunders Elsevier, 2009.
Jafferey P. Okeson, Bells Orofacial pain, 6th
edition, Quintessence publishing co Inc,
2005.
Peterson, Ellis, Hupp, Tucker, Oral and
maxillofacial surgery, 4th edition, Elsevier,
2003.

68. G.C. Manzoni , P. Torelli, Epidemiology of typical
and atypical craniofacial neuralgias, Neurol Sci
(2005) 26: S65–S67
Abhishek singh nayyar, Mubeen Khan, Trigeminal
Neuralgia: Revisiting clinical characteristics in the
Indian scenario. A Journal of Medical science and
Technology. Volume I, Issue 2, August 2012; pages
9-17
Cheryl A. Kitt et al., Topical review Trigeminal
neuralgia: opportunities for research and
treatment, International Association for the Study
of Pain, 2000.

69. THANK YOU