Trigeminal nerve / orthodontic courses by Indian dental academy

TRIGEMINAL
NERVE
1
INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

Contents
• Introduction
• Cranial nerves
• Trigeminal ganglion
• Trigeminal nerve
 Opthalmic branch
 Maxillary branch
 Mandibular branch
• Disturbances associated with trigeminal nerve
 Trigeminal neuralgia
 Paratrigeminal syndrome
 Sphenopalatine neuralgia
 Auriculotemporal syndrome
• Nerve blocks associated with trigeminal nerve branches
• Clinical examination of trigeminal nerve
• Trigeminal nerve injuries
• Conclusion
• References 2www.indiandentalacademy.com

NERVOUS SYSTEM
Central nervous system
Peripheral nervous
system
Brain and spinal cord
Autonomic and somatic
nervous system
I
N
T
R
O
D
U
C
T
I
O
N
B.D. Chaurasia 4th edition
3www.indiandentalacademy.com

Structure of nerve
Axon
Fasciculi
Nerve fibre
Nerve
Endoneurium
Perineurium
Epineurium
I
N
T
R
O
D
U
C
T
I
O
N
Peter. L. Williams, grays anatomy, 38th edition,1995

C
R
A
N
I
A
L
N
E
R
V
E
S
Motor nerves: III IV VI XI
XII
Sensory nerves I II VIII
Mixed nerves V VII IX X
Associated with
parasympathetic ganglion
III VII IX X
Peter. L. Williams, grays anatomy, 38th edition,1995 5www.indiandentalacademy.com

T
R
I
G
E
M
I
N
A
L
G
A
N
G
A
L
I
O
N
Trigeminal gangalion
Gasserian/semilunar
Sensory cell bodies of
three branches of
trigeminal
Lies in a depression on
the petrous apex, within a
dural fold called the
meckal cave
Cunningham’s manual of practical anatomy, volume 3,
3rd edition 6www.indiandentalacademy.com

7
Trigeminal nerve
overview

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
Trigeminal nerve
Tres meaning three and
geminus meaning twin Largest cranial nerve
Mixed nerve
Sensory to greater part of
the scalp, teeth and the
oral and nasal cavity
Motor supply is to
muscles of mastication
and extraocular muscles
5th cranial nerve

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
MOTOR ROOT SENSORY ROOT
TWO ROOTS
Within pons and medulla
oblongata
Semilunar gangalion
Foramen ovale along with
mandibular nerve
MOTOR ROOT
Muscles of mastication
Mylohyoid
Anterior belly of digastric
Tensor tympani
Tensor veli palatine
3rd edition

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
SENSORY ROOT
Fibres arise in trigeminal
ganglion
Opthalmic nerve
Leaving from concave
surface of ganglion
3rd edition 10
Maxillary nerve
Mandibular nerve

B
R
A
N
C
H
E
S
Main divisions
Opthalmic
Wholly Sensory division
Superior and smallest
division
Leaves cranium through
Superior orbital fissure
3 branches
Lacrimal
Frontal
Nasocilliary

O
P
T
H
A
L
M
I
C
N
E
R
V
E Peter. L. Williams, grays anatomy, 38th edition,1995

O
P
T
H
A
L
M
I
C
N
E
R
V
E
Lacrimal nerve
Smallest branch
Ends in the skin of upper
eyelid
Lacrimal gland and
conjunctiva
Pierces orbital septum

O
P
T
H
A
L
M
I
C
N
E
R
V
E
Frontal nerve
Largest branch
Skin of forhead and scalp
Mucous membrane of
frontal sinus and
pericranium
Enter orbit through
superior orbital fissure
Supraorbital branch Supratochlear branch
Upper eyelid
Lower part of forhead

O
P
T
H
A
L
M
I
C
N
E
R
V
E
Nasocilliary nerve
Branches in orbit
In nasal cavity
Supply mucous
membrane of nose
Branches in nasal cavity
Long ciliary nerve
Supply iris , cornea
Posterior ethmoi nerve
Posterior
ethmoid,sphenoidal air
cells
Anterior ethmoidal nerve
Anterior ethmoid, frontal
paranasal
Nasal conchae, anterior
nasal wall
Tip and ala of nose
On face supply lacrimal
gland. Both eyelids and
skin over nasal bridge
Branches on face
 B.D. Chaurasia 4th edition

M
A
X
I
L
L
A
R
Y
N
E
R
V
E
Maxillary nerve
Wholly sensoryBegins at trigeminal
ganglion
Enter orbit through
inferior orbital fissure
and appears on face
through infra orbital
foramen
Leaves through foramen
rotundum

M
A
X
I
L
L
A
R
Y
N
E
R
V
E
Maxillary nerve branches
Cranium
Pterygopalatine fossa
Infraorbital canal
Face
Cranium
Pterygopalatine fossa
Infraorbital canal
Face

M
A
X
I
L
L
A
R
Y
N
E
R
V
E
Middle superior alveolar
nerve
Anterior superior
alveolar nerve
Posterior superior
alveolar nerve

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Largest division
Large sensory root, small
motor root
Mandibular nerve
Motor root medial to
sensory
Main trunk 2-3mm
Small anterior and large
posterior branch

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Branches of mandibular
nerve

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Meningeal branch
Nerve to medial
pterygoid
Branches of undivided
nerve
Enter skull through
foramen spinosum
Supply dura of middle
and anterior cranial fossa
Slender branch
Supply deep part of
muscle
Also tensor tympani and
tensor velli palati muscle

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Buccal nerve
Anterior division
Passes between two
heads of lateral pterygoid
Emerge under ramus and
anterior border of
masseter
Supply skin over anterior
part of buccinator and
mucous membrane lining
buccal surface of gums

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Massetric nerve Passes through
mandibular notch
Deep temporal nerve
Nerve to lateral pterygoid
Supply masseter muscle
Passes above upper head
of lateral pterygoid
Turn above infratemporal
crest and sink into
temporalis
2 branches supplying
each muscle head

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Branches of posterior
division
Auriculotemporal nerve
Traverse upper part of
parotid gland
Auricular branch
Articular branch
3rd edition 24
Temporal branch

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Lingual nerve
Lies between ramus and
medial pterygoid.
Antriomedial to inferior
alveolar nerve
Base of tongue behind 3rd
molar
Medial to submandibular
duct

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Carries sensation from
Anterior two third of the
tongue
Oral mucosa on the floor
of the oral cavity
Lingual gingiva associated
with lower teeth

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Inferior alveolar nerve
Large terminal branch of
posterior division
Originates deep to the
lateral pterygoid muscle
in association with
lingual nerve
Passes between
sphenomandibular
ligament and ramus

M
A
N
D
I
B
U
L
A
R
N
E
R
V
E
Mylohyoid branch which
supply mylohyoid muscle
Enter the mandibular
foramen
Branches into mental
nerve and incisive nerve

I
N
T
R
O
D
U
C
T
I
O
N

g
a
n
g
l
i
o
n
Ganglion associated with
trigeminal nerve:

g
a
n
g
l
i
o
n
Ciliary ganglion
Sensory root
Sympathetic root Plexus around opthalmic
artery
Nasocilliary nerve
Parasympathetic root Occulomotor nerve

g
a
n
g
l
i
o
n
Only structurally related
to maxillary nerve
Sphenopalatine/Pterygopalatine
gangalion
32
Sensory root
Sympathetic root
Plexus around internal
carotid artery
Maxillary nerve
Secrotomotor root Greater petrosal nerve

g
a
n
g
l
i
o
n
Nasal
Sphenopalatine/Pterygop
alatine gangalion
Palatine
Orbital
33
Pharyngeal

g
a
n
g
l
i
o
n
Otic ganglion
Parasympathetic ganglion
Topographically –
Mandibular nerve
Functionally –
Glossopharyngeal nerve
Situated in infratemporal
fossa below foramen
ovale

g
a
n
g
l
i
o
n
Otic ganglion
35
Sensory root
Sympathetic root
Plexus around middle
meningeal artery
Auriculotemporal nerve
Secrotomotor root Lesser petrosal nerve

g
a
n
g
l
i
o
n
Submandibular ganglion
Lies superficial to
hyoglossus muscle in
submandibular region
Topographically – lingual
branch of mandibular
nerve
Fumctionally – Facial
nerve

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Trigeminal neuralgia
Fothergill’s disease/Tic
douolourex
Sudden, unilateral,
lancinating, recurrent
pain
Right side more
commonly effected
Cranial nerve functional anatomy, Stanley Monkhouse 37
Attack last from few
seconds to several
minutes
Presence of trigger zones

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Etiology
Intracranial tumours
Intravascular
abnormalities
Multiple sclerosis Post traumatic neuralgia
Viral etiologyDental etiology

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Pathophysiology
Cranial nerve functional anatomy, Stanley Monkhouse 39www.indiandentalacademy.com

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Bilateral cases
Maxillary division
Mandibular division
Opthalmic division
All 3 divisions
Both maxi and
mandibular
3 %
66%
49%
16%
19%
1%

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Treatment
Peripheral neurectomy Alcohol injection into
peripheral nerve area
Injection of boiling water
into ganglion
Surgical sectioning of
trigeminal sensory root
Microsurgical
decompression of
trigeminal root

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Paratrigeminal
syndrome/Raeder’s
syndrome
Middle aged males
Severe hedache pain in
area distibution of
trigeminal nerve
Signs of ocular
sympathetic paralysis
No sweating on the
affected side

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Sphenopalatine neuralgia
Lower half
headache/Sludders
headache
Vasoconstriction of
vessels supplying nasal
mucosa
Deviated nasal septum Vasodialation of internal
maxillary artery

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Sphenopalatine neuralgia
Unilateral paroxysm of
intense pain for 15 min to
several hours
Alarm clock hedache
Male > female
1st episode occur before
40 years of age
Sneezing, discharge and
epiphoraNo trigger zones

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Treatment
Alcohol injection into the
ganglion
Surgical correction of
septal defects
Drugs like ergotamine
and methysergideResection of ganglion

D
I
S
T
U
R
B
A
N
C
E
S
A
S
S
O
C
I
A
T
E
D
Auriculotemporal
syndrome
Frey syndrome
Due to reinnervation of
sweat glands by
parasympathetic salivary
fibres
Mainly after some
surgical operation like
removal of parotid gland
Sweating and flushing of
the involved side during
eating

N
E
R
V
E
B
L
O
C
K
S
Posterior superior
alveolar nerve block
Tuberosity
block/zygomatic block
Pulp of maxillary 3rd
molar, 2nd and 1st molar
(except MB root of 1st
molar), buccal
periosteum and bone
Malamad SF. Handbook of local anesthesia. 6th ed. Missouri: Elsevier;201347www.indiandentalacademy.com

N
E
R
V
E
B
L
O
C
K
S
Middle superior alveolar
nerve block
Pulps of maxillary 1st and
2nd premolar, MB root of
1st molar, buccal
periosteum and bone

N
E
R
V
E
B
L
O
C
K
S
Anterior superior
alveolar nerve block
Infraorbital nerve block
Pulp of maxillary central
incisor to the canine.
In 72% of cases pulp of
maxillary premolars and
MB root of 1st molar.
Buccal periosteum and
bone of these teeth.
Lower eyelid, lateral
aspect of nose, upper lip.

N
E
R
V
E
B
L
O
C
K
S
Greater palatine nerve
block
Anterior palatine nerve
block
Posterior portion of hard
palate and overlying
tissues, anteriorly till the
1st PM and medially till
the midline.

N
E
R
V
E
B
L
O
C
K
S
Nasopalatine nerve block
Incisive nerve block
Anterior portion of hard
palate and overlying
tissues, mesial from the
right 1st PM to the mesial
of the left 1st PM.

N
E
R
V
E
B
L
O
C
K
S
Maxillary nerve block
Second division block/V2
nerve block
Pulpal anaesthesia of
maxillary teeth on the
side of the block.
Buccal periodontium and
bone overlying these
teeth.
Soft tissue and bone of
the hard palate and part
of the soft palate medial
to midline.
Skin of lower eyelid, side
of nose, cheek and upper
lip.

N
E
R
V
E
B
L
O
C
K
S
block
Mandibular block
Mandibular teeth to the
midline.
Body of the mandible,
inferior portion of ramus.
Buccal mucoperiosteum,
mucous membrane
anterior to mental
foramen.
Anterior 2/3rd of tongue
and floor of oral cavity.
Lingual soft tissues and
periosteum.

N
E
R
V
E
B
L
O
C
K
S
Mandibular nerve bolck
3rd division nerve
block/Gow Gates
technique
midline.
mucous membrane on
the side of injection.
periosteum.
Skin over zygoma and
temporal region.

N
E
R
V
E
B
L
O
C
K
S
Vazirani akinosi tecnique
Closed mouth
mandibular nerve block
midline.
mucous membrane
anterior to mental
foramen.
periosteum.

N
E
R
V
E
B
L
O
C
K
S
Incisive nerve block
Buccal mucous
membrane anterior to
mental foramen till
midline.
Lower lips.
Pulp of premolars,
canines and incisors.

C
L
I
N
I
C
A
L
E
X
A
M
I
N
A
T
I
O
N
Clinical examination of
trigeminal nerve
Use sterile sharp item on
forehead, cheek and jaw.
Sensory function
Motor function
While cleching of teeth,
firmnes of masseter will
be felt on both sides
Trigeminal Nerve Injuries. Michael Miloro;2013 57www.indiandentalacademy.com

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
I
N
J
U
R
I
E
S
Trigeminal nerve injuries
Neuropraxia
Axontmesis
Neurotmesis
Types

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
I
N
J
U
R
I
E
S
Trigeminal nerve injuries

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
I
N
J
U
R
I
E
S
Causes of Trigeminal
nerve injuries
LA injections
Cosmetic surgery
Orthognathic surgery
Maxillofacial trauma
Tumours and oncologic
surgery
Salivary gland surgery

T
R
I
G
E
M
I
N
A
L
N
E
R
V
E
I
N
J
U
R
I
E
S
Extraction of mandibular
3rd molar
Endodontic treatment

Conclusion

REFERENCES:
 Cunningham’s manual of practical anatomy, volume 3,
3rd edition
 Tubbs RS, Loukas M, May WR, Cohen-Gadol AA. A variation of the infraorbital
nerve: its potential clinical consequence especially in the treatment of
trigeminal neuralgia: case report. Neurosurgery. 2010 Sep; 67
 Malamad SF. Handbook of local anesthesia. 6th ed. Missouri: Elsevier;2013
 Peter. L. Williams, grays anatomy, 38th edition,1995
 Trigeminal Nerve Injuries. Michael Miloro;2013
 Cranial nerve functional anatomy, Stanley Monkhouse

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