This document discusses the trigeminal nerve and trigeminal neuralgia. It describes typical and atypical trigeminal neuralgia, their symptoms, and potential causes including compression of the trigeminal nerve by blood vessels. The document outlines treatments for trigeminal neuralgia including medications, surgical procedures like rhizotomy, glycerol injection, and microvascular decompression. It also briefly discusses herpes zoster ophthalmicus and Wallenberg syndrome in relation to trigeminal nerve involvement.

1. TRIGEMINAL NERVE-APPLIED
ANATOMY(PART 2)
DR KHADEEJA KULOOD M
FIRST YEAR PG
DEPT. OF PAEDODONTICS &PREVENTIVE
DENTISTRY

2. TRIGEMINAL NEURALGIA
• Chronic pain disorder that affects the
trigeminal nerve.
• TYPICAL (TN1) and
ATYPICAL(TN2) trigeminal
neuralgia.
• Typical-episodes of severe, sudden,
shock-like pain in one side of the face
that lasts for seconds to a few minutes
• Atypical - constant burning pain that
is less severe
• Both forms may occur in the same
person.
• It is one of the most painful conditions
and can result in depression.
Trigeminal Neuralgia Fact Sheet NINDS November 3, 2015.
National Institute of Neurological Disorders and Stroke

3. fothergill disease
• It is estimated that 1 in 8,000
people per year develop
trigeminal neuralgia
• begins in people over 50 years
old, but can occur at any age
• Women are more commonly
affected than men
• first described in detail in
1773 by John Fothergill
Trigeminal Neuralgia Fact Sheet NINDS November 3, 2015.
National Institute of Neurological Disorders and Stroke

4. Trigger factors
• by vibration or contact with the cheek
• shaving, washing the face, or applying makeup,brushing
teeth, eating, drinking, talking, or being exposed to the wind
• TN is typified by attacks that stop for a period of time and
then return, but the condition can be progressive.
• The attacks often worsen over time, with fewer and shorter
pain-free periods before they recur.
• Eventually, the pain-free intervals disappear and medication
to control the pain becomes less effective.

5. Tic douloureux
• The exact cause is unclear, but believed to involve loss of
the myelin around the trigeminal nerve
This may occur due to
• compression from a blood vessel as the
nerve exits the brain stem.
• multiple sclerosis, stroke, or trauma
• Less common causes include a tumor or
arteriovenous malformation
 Diagnosis is typically based on the symptoms, after ruling
out other possible causes such as postherpetic neuralgia

6. Treatment
• Includes Medication , Surgery & complementary
approaches.
Medication
• Anticonvulsant —used to block nerve firing—are generally
effective in treating TN1 but often less effective in TN2
• Carbamazepine Or Oxcarbazepine is usually the initial
treatment
• Other options include lamotrigine , baclofen , Gabapentin ,
pimozide , valproic acid , topiramate , pregabalin,
clonazepam and phenytoin.

7. Surgery
• Depending on the nature of the pain; the
individual’s preference, physical health, blood
pressure, and previous surgeries
• presence of multiple sclerosis, and the
distribution of trigeminal nerve involvement
(particularly when the upper/ophthalmic
branch is involved)

8. Associated risks
• Some degree of facial numbness is expected
after many of these procedures, and TN will
often return even if the procedure is initially
successful.
• Depending on the procedure, other surgical
risks include hearing loss, balance problems,
leaking of the cerebrospinal fluid, infection,
anesthesia dolorosa and stroke.

9. RHIZOTOMY ( rhizolysis )
• Procedure in which nerve fibers are damaged to block pain.
• A rhizotomy for TN always causes some degree of sensory loss and
facial numbness.
• Several forms of rhizotomy are available to treat trigeminal neuralgia
:
I. Balloon compression
II. Glycerol injection
III. Radiofrequency thermal lesioning
(Radiofrequency Ablation)
IV. Stereotactic radiosurgery(Gamma
Knife, Cyber Knife)
V. Microvascular decompression (MVD)

10. Balloon compression
• works by injuring the
insulation on nerves that are
involved with the sensation of
light touch on the face.
• performed under general
anesthesia.
• A tube called a cannula is
inserted through the cheek and
guided to one branch of the
trigeminal nerve that passes
through the base of the skull

11. • A soft catheter with a balloon tip is threaded through the cannula and the
balloon is inflated to squeeze part of the nerve against the hard edge of the
brain covering (the Dura) and the skull.
• After about a minute the balloon is deflated and removed, along with the
catheter and cannula.
• Balloon compression is generally an outpatient procedure, although
sometimes the patient may be kept in the hospital overnight
• Pain relief usually lasts one to two years.

12. Glycerol injection
• Outpatient procedure in which the
individual is sedated with
intravenous medication
• A thin needle is passed through the
cheek, next to the mouth, and
guided through the opening in the
base of the skull where the third
division of the trigeminal nerve
(Mandibular) exits
• The needle is moved into cistern
that surrounds the trigeminal nerve
center (or ganglion)
• .

13. • The procedure is performed with the person
sitting up, since glycerol is heavier than
spinal fluid and will then remain in the
spinal fluid around the ganglion
• The glycerol injection bathes the ganglion
and damages the insulation of trigeminal
nerve fibers.
• This form of rhizotomy is likely to result in
recurrence of pain within a year to two
years

14. Radiofrequency thermal lesioning
• Most often performed on an outpatient
basis.
• The individual is anesthetized and a
hollow needle is passed through the
cheek
• The individual is briefly awakened and
a small electrical current is passed
through the needle, causing tingling in
the area of the nerve where the needle
tips rest
• When the needle is positioned so that
the tingling occurs in the area of TN
pain, the person is then sedated and the
nerve area is gradually heated with an
electrode, injuring the nerve fibers.

15. Stereotactic radiosurgery
• uses computer imaging to
direct highly focused
beams of radiation at the
site where the trigeminal
nerve exits the brain stem.
• This causes the slow
formation of a lesion on the
nerve that disrupts the
transmission of sensory
signals to the brain.
• almost half have recurrence
of pain within three years.

16. Microvascular decompression
• most invasive of all surgeries for TN, but
better prognosis more often.-within 12 to 15
years
• performed under general anesthesia, requires
that a small opening be made through the
mastoid bone behind the ear.

17. • While viewing the trigeminal nerve through a
microscope or endoscope, the surgeon moves
away the vessel (usually an artery) that is
compressing the nerve
• places a soft cushion between the nerve and
the vessel

18. Complementary approaches
• usually in combination with
drug treatment
• low-impact exercise, yoga,
creative visualization, aroma
therapy, or meditation may be
useful in promoting well-being
• Other options include
acupuncture, biofeedback,
vitamin therapy, and
nutritional therapy
• Injections of botulinum toxin
to block activity of sensory
nerves

19. Herpes Zoster Ophthalmicus
• Caused by Varicella zoster
• Predilection for nasociliary branch of ophthalmic
division of the trigeminal nerve.
CLINICAL FEATURES:-
Cutaneous lesions:-
• Rash
• Vesicle
• Pustule crust permanent scar

20. Ocular lesions:-
• Periorbital pain and Oedema
• Hyperasthesia
• Conjunctivitis
• Scleritis
• Corneal scarring
• Glaucoma
TREATMENT:-
 Acyclovir 800mg 5 times /day within 4 days of onset of rash
 Analgesics
 Antibiotic ointments
 Systemic steroids 60mg/day
 Corneal grafting

21. Wallenberg syndrome(lateral
medullary syndrome)
• A stroke usually affects only one side of the
body.
• loss of sensation due to a stroke will be
lateralized to the right or the left side of the
body
• In this syndrome, a stroke causes a loss of
pain,temperature sensation from one side of
the face and the other side of the body

22. • In the medulla, the ascending
spinothalamic tract (which carries pain-
temperature information from the
opposite side of the body) is adjacent to
the ascending spinal tract of the
trigeminal nerve (which carries pain-
temperature information from the same
side of the face)
• A stroke which cuts off the blood supply
to this area destroys both tracts
simultaneously
• The result is a loss of pain-temperature
sensation in a "checkerboard" pattern
(ipsilateral face, contralateral body),
facilitating diagnosis.

23. Conclusion
Anatomy of trigeminal nerve and its
branches plays an important role in dentistry.
Application of local anaesthesia and certain
surgical procedures requires a thorough
knowledge of its anatomy.

24. Thank you