1. TRIGEMINAL NERVE
Presented To:
Dr. Viniti Goel (Professor and
Head)
Dr. Deepak Bala (Reader)
Dr. Shikha, Dr. Jaspreet
Dr. Sarvani, Dr Vikram Dr.
Sonam
1
GUIDED BY
DR VINITI GOEL
PRESENTED BY
MALTI RANI
PERIODONTOLOGY AND IMPLANTOLOGY
2. CONTENTS
Introduction
Origin and associated nuclei
Course
Divisions
Branches
Description of course and
branches
Ganglia associated with
trigeminal nerve
Examination of trigeminal nerve
Dental Plexus
Clinical Application
2
4. NERVE & GANGLIA
NERVE: Bundles of axons in the
PNS are referred to as nerves.
These structures in the periphery
are different than the central
counterpart, called a tract.
A ganglion is a group of neuron cell
bodies in the peripheral nervous
system.
TRACTS :
4
5. Introduction
The largest cranial nerve
Described by Fallopius and again by Meckel in 1748.
Name trigeminal was given by Winslow on account of its three divisions.
Carries General somatic afferent (GSA) and Branchial efferent (BE) fibres.
It is mixed nerve ( sensory and motor )
Sensory to – Skin of face
-Mucosa of cranial viscera
-Except base of tongue and pharynx
Motor to –Muscles of Mastication
-Tensor veli palatini, Tensor tympanI
-Anterior belly of digastric
-Mylohyoid
5
6. origin
Emerges from Anterolateral
surface of Pons which is a part of
the brainstem.
As a large sensory root and a small
motor root.
The trigeminal nerve emerges
from the pons and extends
through Posterior and Middle
cranial Fossa.
Sensory root Forms Trigeminal
Ganglion (Gasserian/Semilunar
Ganglion
6
7. The sensory nuclei –
largest of the cranial nerve nuclei
extend through whole of the brainstem.
1. The mesencephalic nucleus
- proprioception
2. The chief sensory nucleus (or "pontine
nucleus" or "main sensory nucleus"
or("primary nucleus") – touch
3. The spinal trigeminal nucleus
– pain & temperature.
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ASSOCIATED NUCLEI
8. It supplies 8 muscles derived from first branchial arch
i.e
Temporalis,
Masseter,
Medial pterygoid
Lateral Pterygoid
Tensor veli Palatini
Tensor Tympani
Mylohyoid
Anterior belly of Diagastric
8
MOTOR NUCLEUS :
Innervates muscles of mastication and
tensor
tympani and tensor palatini
Derived from first branchial arch.
Located in pons medial to principle
sensory nucleus.
9. COURSE & DISTRIBUTION
Both motor and sensory root are attached ventrally to
junction of pons and middle cerebellar peduncle with
motor root lying ventromedially to the sensory root.
Pass anteriorly in middle cranial fossa to lie below
tentorium cerebelli in cavum trigeminale, here motor root
lies inferior to sensory root.
9
10. Sensory root connected to postromedial concave
border of the trigeminal ganglion.
Convex antrolatateral margin of the ganglion gives
attachment to the 3 div. Of the trigeminal nerve.
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11. Motor root turns further inferior with sensory
component of V3 to emerge out of foramen Ovale as
Mandibular nerve.
Ophthalmic and Maxillary division emerges through
Superior orbital fissure and foramen Rotundum
respectively
11
13. Divisions of trigeminal nerve 13
Divides into 3 Branches
Opthalmic Nerve
Maxillary Nerve
Mandibular Nerve
14. Opthalmic Nerve
OPHTHALMIC NERVE
Smallest division.
Sensory only
Supplies : eyeballs, conjunctiva, lacrimal gland,
mucosa of nose and paranasal sinus, skin of forehead
eyelid and nose
14
15. Course of ophthalmic nerve
emerges from trigeminal ganglion
lateral wall cavernous sinus
3 branches in ant part of cavernous sinus
lacrimal, naso-cilliary, frontal
superior orbital fissure
orbit
15
16. Branches
Lacrimal nerve
Passes into orbit through lateral compartment of the Superior orbital fissure
outside the tendinous ring.
Receives communicating branch from Trochlear nerve branch of Opthalmic
nerve.
Communicate with branch from Zygomaticotemporal nerve branch of maxillary so
parasympathetic fibres (secretomotor) associated with pterygopalatine ganglion
are conveyed to lacrimal gland.
16
Sensory to lateral
conjunctiva, Upper Lid, lacrimal
gland
Post synaptic
parasympathetic fibers from
pterygopalatine
ganglion to lacrimal gland
(parasympathetic
secretomotor
17. FRONTAL NERVE
Largest
Enters orbit through lateral part of superior
orbital fissure outside tendinous ring
Passes forward between roof of orbit and
Levator Palpebral Superioris
Supratrochlear
Nerve
Divides into :
Supraorbital Nerve
17
Supra Trochlear- Conjunctiva covering upper
eyelid and lower part of forehead.
Supra Orbital- Mucous membrane of frontal
air sinus, skin and conjunctiva over upper
eyelid, skin over scalp and forehead.
18. NASOCILLIARY NERVE
Nasociliary nerve (runs medially):
Short Clliary Nerves: Fibers reaches
eyeball and also contains fibers from
Cilliary Ganglion
2. Long Cilliary Nerves : 2 or 3in no.
supply to Iris and Cornea.
3. Post Ethmoidal Nerve: passes
through posterior ethmoidal foramen
to supply the Ethmoid and Sphenoid
PNS.
4. Infratrochlear Nerve: appears on
face above med angle the eye.
Supplies to skin of lacrimal sac and
caruncle.
18
Purely Sensory
Passes through middle part of superior orbital fissure within the
tendenious ring.
5 branches in orbit.
19. 5.Anterior Ethmoidal Nerve:
larger terminal branch
Course: anterior ethmoidal foramen and canal
into anterior cranial fossa on sup surf of cribriform plate
Through slit lat to crista galli into nasal cavity
Medial internal nasal branch lateral 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
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20. MAXILLARY NERVE
Second division of trigeminal nerve
Purely sensory
Supplies derivatives of maxillary process and
frontonasal process
20
21. Trigeminal ganglion-> Middle cranial fossa
Lateral wall of cavernous sinus
Foramen rotundum
Pterigopalatine fossa
In groove on posterior surface of maxilla
Through inferior orbital fissure into orbit as INFRA ORBITAL Nerve
Through infraorbital foramen on face
21
COURSE
After leaving foramen rotundum it moves anteriorly inthe uppermost part of
pterygopalatine fossa.
As it passes through pterygopalatine fossa it also gives branches to sphenopalatine
ganglion, posterior superioralveolar nerve and zygomatic branches.
23. WITHIN CRANIUM
Middle meningeal nerve
- travels with middle meningeal artery
- supplies duramater
IN PTERYGOPALATINE FOSSA
1. ZYGOMATIC NERVE
enters orbit through inferior orbital fissure ,
it gives 2 branches within inferior orbital fissure
Zygomaticotemporal
Zygomaticofacial
Posterior superior Alveolar nerve
Ganglionic Branches The pterygopalatine ganglion gives rise to the
following nerves: the nasopalatine nerve, the lesser palatine nerve, the
greater palatine nerve, the posterior superior lateral nasal nerves, the
posterior inferior lateral nasal nerves, and pharyngeal nerve.
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27. Mandibular Nerve
Largest
Mixed
Nerve of 1st branchial arch
Motor root- from
motor nucleus in pons sensory root- gasserian ganglion
exit through foramen ovale in greater wing of sphenoid from trunk which remain 2-3 mm
undivided in infra-tempora lfossa
travels between lat. Pterygoid and Otic ganglion laterally and
tensor palatine medially anteriorly to med. Meningeal
a small ant. Division A large post. division
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31. From main trunk:
Nervus spinosus(SENSORY) – Supplies dura
and mastoid cells
Nerve to Medial pterygoid(MOTOR) - Supplies
medial pterygoid, tensor veli palatini and
tensor tympani
From Anterior trunk: (PRIMARILY MOTOR)
Buccal nerve is the only sensory branch of ant
div. travels b/w heads of lateral pterygoid and
emerges in cheek at ant border of masseter.
Supplies skin and mucous membrane of
cheek. supply the buccinator muscle. It
supplies: a branch to the lateral pterygoid
muscle. a filament to the anterior deep
temporal nerve for the temporalis muscle
Masseteric nerve
Deep temporal
Nerve to lateral pterygoid
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33. Auriculo-temporal nerve- supply the tragus of the pinna of the
external ear, to the scalp about the ear, and as far as the vertex of the
skull. Also provides secretomotor fibres to PAROTID
Lingual nerve - It provides both general sensation and gustation to
anterior 2/3 of tongue.
Inferior alveolar nerve
Largest terminal branch
lies deep to the lateral pterygoid muscle.
Separated from the medial pterygoid by sphenomandibular ligament.
In mandibular canal, it gives branches that supply teeth.
As it reaches the region of the mental foramen it divides into 2
terminal branches-
mental nerve - supplies the skin of chin and lower lip
incisive nerve - supplies the cuspid and the incisor teeth.
A mylohyoid branch supplies fibers to the anterior belly of diagastric
muscle.
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35. Ganglia Associated With The
Trigeminal Nerve
1.Cilliary Ganglion: connected with nasocilliary nerve by ganglionic branches
in orbit,
non synapsing
sensory for orbit
2.Pterygopalatine Ganglion: connected to maxillary nerve in infratemporal
fossa
sensory to orbital septum, orbicularis and nasal cavity, max sinus, palate,
nasopharynx.
3. Otic Ganglion: betwn trunk of mandibular n and tensor palatini, nerve to
med pterygoid passes thru but does not synapse in the ganglion.
4.Submandibular Ganglion: related to lingual n, rests on hypoglossus
supplies post gang. Parasym secretomotor fibres to submandibular and
sublingual gland.
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37. CUTANEOUS DISTRIBUTION OF
TRIGEMINAL NERVE
Each half of face is supplied by 13 cut N
1motor and 12 sensory
Of 12 sensory : 11 are from trigeminal N
1 is c2 greater auricular N
Branches of trigeminal N
5 from ophthalmic: lacrimal
supraorbital
supratrocheal
infratrochlear
external nasal
1/20/2015 Oral And Maxillofacial Surgery
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38. 3 from maxillary N: infra orbital N
zygomaticofacial N
zygomaticotemporal N
3 from mandibular N: buccal N
auriculotemporal N
mental N
DIVISIONAL SUPPLY:
From lat canthus to vertex- ophthalmic N
From angle of mouth to vertex- mandibular
N
Between the two areas-maxillary N
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39. Dental plexus
Network of nerves
Terminal branches of larger nerves in the region
Innervate individual roots of all teeth, bone and
periodontal structures
SUPERIOR DENTAL PLEXUS
Small nerve fibers from three superior
alveolar nerves
Anterior
Middle
Posterior- superior alveolar nerves
INFERIOR DENTAL PLEXUS
Derived from inferior alveolar nerve and its branches on both
sides
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42. CLINICAL APPLICATION
Causes of injury to trigeminal nerve –
1. Maxillofacial surgical procedures
Orthognathic surgeries
third molar odontotomy
salivary gland surgeries
head & neck pre-prosthetic surgeries
Treatment of benign & malignant lesions
2. Trauma & facial fractures
3. Dental implant placement
4. Endodontic therapy
5. Treatment of pathology (specially periapical)
6. During administration of local anesthesia
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43. Effects of injury or disease-
causes paralysis of the muscle supplied
loss of sensation in the area of supply.
Neural damage is characterized by loss or gain in
sensation (negative or positive symptoms) as well as
other pain conditions (neuropathic pain, trigeminal
neuralgia) .
The negative symptoms (sensory deficits) present
themselves as anaesthesia or hypoesthesia and positive
symptoms as paresthesias , dysesthesias and
hyperesthesia among others .
Nerve laceration and excessive nerve manipulation are
commonest cause of nerve disturbance after oral
treatment.
46
44. TRIGEMINAL NEURALGIA –
TIC DOULOUREUX
Definition It is defined as sudden, usually unilateral, severe,
brief, stabbing, lancinating, recurring pain in the
distribution of one or more branches of the Vth cranial
nerve.
Paroxysmal attacks of facial or frontal pain , lasting a few
seconds to less than 2 minutes.
relatively common
paroxysm of sudden intense,
shocking, stabbing onset of facial pain
Involves One or more areas of
distribution Of the trigeminal Nerve
maxillary and mandibular
divisions are commonly involved
Attacks do not occur during sleep
In extreme cases, the patient will have a motionless face –
the ‘frozen or mask like face’.
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45. local lesions ophthalmic division : acute glaucoma
frontal sinusitis
maxillary division : caries
carcinoma of maxilla
empyema of maxillary sinus
mandibular division : caries
carcinoma or ulcer of tongue
etiology
Demylination of the nerve
Post – traumatic neuralgia
Petrous ridge compression
Intracranial vascular abnormalities
Viral etiology
Intracranial tumours
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46. Trigger zones are triggered during impression
making, jaw relation and establishing occlusion
during fabrication of dentures.
Trigger zones are also stimulated in old patients
having overclosure denture
Common trigger zones include:
Cutaneous Intraoral
Teeth Corner of the lips
Cheek Tongue
Ala of the nose Gingivae
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47. TREATMENT
1.Pharmacological
Carbamazepine - 200 mg/day (Maintenance dose- 400-1200 mg/day)
Baclofen – 10 mg/day
Phenytoin- 300mg/day
Oxcarbazepine – 300 mg/day
2. Surgical
Alcohol injection
Peripheral Rhizotomy
Microsurgical Rhizotomy
Radiofrequency rhizotomy
Microvascular decompression of the nerve at pons
Percutaneous glycerol rhizotomy
Balloon compression rhizotomy
The goal of a number of surgical procedures is to either damage or destroy the
part of the trigeminal nerve that's the source of pain.
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48. MAXILLARY SINUS
INFECTIONS
Infections of the maxillary sinus may cause
infraorbital pain or
may cause referred pain to other structures
supplied by Vb (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
Hay fever
This is usually allergic,
but the symptoms could be produced by
involvement of parasympathetic “fellow travellers”
with the maxillary nerve.
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49. Trigeminal neuropathy
sensory loss of face or weakness of the jaw muscles
causes- SLE, sjogren syndrome
herpes zoster, leprosy
meningioma, schwanomma
Wallenberg syndrome
vertebral artery occlusion
infarction of lateral medulla
symptoms - ipsilateral facial sensory loss,
ipsilateral horners,
ipsilateral IX,X,XI palsy
ipsilateral cerebellar ataxia ,
contralateral sensory los
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50. SPHENOPALATINE NEURALGIA
Vasodilatation of the internal maxillary artery near the region
of Sphenopalatine Ganglion
Unilateral paroxysms of intersperse pain in the region of
eyes, maxilla,
ear, mastoid base of the nose and beneath the zygoma
There are no TRIGGER ZONES
Treatment
- Alcohol injection
-prednisolone, ergotamine, verapamil
- Resection of the ganglion
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51. AURICULOTEMPORAL
SYNDROME
It results from damage to the Auriculotemporal nerve. The
syndrome usually follows some surgical operation .
CLINICAL FEATURES
Flushing and sweating of the involved side of the face along
the distribution of auriculotemporal nerve.
These signs occurs in response to gustatory stimuli.
TREATMENT
Intracranial division of Auriculotemporal nerve
Botulinum toxin injection
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52. Herpes zoster ophthalmicus:
It is a viral infection caused by herpes virus that produces
lesions in the cranial or spinal ganglia
HHV3 / vericella zoster most commonly
most frequently affecting nasociliary branch
Gasserian ganglion
ophthalmic nerve
Supraorbital Nerve. Infraorbital N.
Supratrochlear Nerve.
Infratrochlear Nerve.
Nasal Nerve.
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53. visual morbidity
Pain precedes skin lesion
clinical feature is
hemifacial unioccular
Cutaneous lesions–
Maculopapular rash
Vesicle
Pustules
Crust
Permanent scar
Treatment
PHN- anlgesic, anti depressants, trigeminal rhizotomy and
stellate ganglion block
The drug of choice is antiviral drugs like acyclovir (800mg/5 times),
analgesics and antibiotic ointments
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54. STURGE WEBER SYNDROME
encephalotrigeminal angiomatosis
port-wine stain
rare congenital neurological & skin disorder
often associated with port-wine stains of the
face, glaucoma, seizures, mental retardation
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55. CAUSALGIA (COMPLEX
REGIONAL PAIN SYNDROME)
Is a burning pain and paresthesia associated with
deformation of nerves
Seen after surgical tooth extraction
TREATMENT
Injection of procaine ,alcohol
Surgical curettage of bone or Resection of nerves
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56. Peripheral trigeminal neuropathic pain
Traumatic nerve injury leads to peripheral neuropathic pain. It can be
diagnosed by tapping (Tinel’s sign) or pressing the suspicious site of nerve
injury.
Pain can be relieved by applying topical anesthetic agent (benzocaine)
followed by nerve block by lidocaine.
Mandibular nerve paralysis
Some central and peripheral lesions of trigeminal nerve also causes motor
dysfunction and atrophy of muscles supplied by mandibular nerve.
In unilateral paralysis, during mouth opening mandible deviates towards
ipsilateral side due to normal lateral pterygoid muscles in contralateral side.
In bilateral paralysis, there will be dropping of the mandible.
Burning Mouth Syndrome
Burning sensation of mucosa / lips or tongue and altered taste sensation.
There is absence of any lesion.
Causes- Xerostomia , sensory nerve damage, GERD, Geographic tongue,
vitamin B12 ,Iron deficiency.
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57. Neuritis
Inflammation of nerve
Trigeminal neuritis involve alveolar nerve branches.
Pain in and around teeth, PDL Structures- frequent
complaint.
Weakness and paralysis of masticatory muscles- When V3
involved.
Marcus-Gunn Jaw Winking Syndrome
On movement of jaw, an associated winking motion of
affected eyelid is seen. An aberrant connection exists
between Cranial Nerve V 3 and CN III.
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58. Raeder’s paratrigeminal syndrome
Pulling pain over the left zygomatic region
which radiated two days later to an area behind & below the
left ear.
Pain presented at mourning & reoccurred at
nigtht .
Wooshing & buzzing sound in left ear.
Numbness over the left side of face.
Blurred vision.
Unable to bite.
Left nostril appeared blocked.
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59. Gradenigo’s syndrome
Petrous bone osteitis due to
suppurative otitis media
Characterized by -
- ipsilateral trigeminal Nerve
palsy (Va, Vb)
- retro orbital pain
- ipsilateral sixth N palsy
62
60. Trigeminal nerve branch injuries associated
with different Procedures
Nerve damage resulting from trauma, local anaesthesia and endodontics
result in transient nerve damage recovering over time.
Oral pathology, orthognathic surgery, implant placement and tooth extraction
have the greatest risk of causing long-term nerve damage
The treatment varies from physiotherapy to cryosurgery, anaesthetic injection
and nerve transection. These treatments are usually in combination with
medication
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61. Complications using implant
surgery
It is suspected that the drill preparation can
violate the mandibular canal with poor
technique, even though the post-operative
radiograph of the implant in place shows the
implant to be the appropriate 2mm above the
canal. If the patient has
anesthesia/paresthesia/dysesthesia
symptoms, the dentist should know that
he/she may have injured the inferior alveolar
nerve with the drill when placing the implant
or the implant is in the canal or impinging on
the canal putting pressure on the inferior
alveolar nerve
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62. 65
During implant placement, there is chance for damage to the
inferior alveolar nerve, mental nerve and incisive nerve in mandibular
region nasopalatine canals, and posterior alveolar nerve in maxillary region.
The zygomatico facial nerve and infraorbital nerve are frequently injured
during zygomatic implant placement and during reflection of the soft tissue
over it.
There will be loss of the sensation in the check region.
The nerve injuries by implant fixtures
occur during drilling and compression
of bone producing, hematoma,
edema, abnormal mandibular nerve
canal, and reactive bone
augmentation. In some patients, there
is thinning of missing of upper layer of
bone surrounding the mandibular
canal, leading to fracture if peri-
implantitis occur.
Greater palatine nerve injury is
detected during implant placement in
pterygomaxillary areas.
63. Management
The use of acceptable preoperative analgesics/anesthetics/ both, during the
operative procedures reduce the risk of postoperative neuropathic pain.
CBCT should also be considered, where a 3D anatomical representation will
significantly enhance the information of implant osteotomy/bone augmentation
sites.
It is recommended that a clearance of at least 3mm of bone should be left from the
top of the mandibular canal, 5mm from mental foramen and 1mm from nasal cavity
and maxillary sinus.
Historically, nerve injury during implant procedure occurs due to vestibular incision
hence currently midcrestal and intrasulcular incision is used.
Full mucoperiosteal flap without stretching and vertical releasing incision is
recommended on the lingual aspect of mandible to avoid lingual nerve damage.
To prevent nerve injury during implant placement, drill guards are used.
If nerve injury occurs due to implant placement unscrewing of the implant is done
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64. Examination of trigeminal
nerve
1- Sensation Function
2- Motor Function
3- Corneal reflex
4- Test jaw jerk
Purpose of test -Is there any loss of senssation ????
2. Where the lesion is present ????
- peripheral branches
gasserian ganglioFor touch
2. For pain & temperatureTest skin sensation of lower eyelid, cheek and
upper lip.
67
65. Three simple clinical tests for trigeminal nerve function:
(1) sensation: apply gentle touch, pinpricks, or warm or cold
objects to areas supplied by the nerve and note responses;
(2) reflex: try the jaw jerk and eye and sneeze reflexes;
(3) motor function: test the patient’s ability to chew and work
against resistance and observe contraction of the massater and
temporal muscles by visual examination and digital palpation.
- Sensation function
- use sterile sharp item on forehead, cheek, and jaw
- If any abnormality present we test the thermal
- sensation and light touch
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66. Motor Function 69
Test motor function of trigeminal nerve b y palpating
and squeezing the temporal and masseter muscles.
67. Corneal reflex
a clean piece of cotton wool and ask the patient to look away
gently touch the cornea with the cotton wool and the patient will
blink.
Test jaw jerk
Doctor finger on tip of jaw, grip patellar hammer
halfway up shaft and tap finger lightly usually nothing happens,
or just a slight closure.
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68. ABNORMALITIES OF
SENSATION
TOTAL LOSS OF SENSATION OVER WHOLE DISTRIBUTION
NERVE
Causes –
1. Lesion of ganglion.
2. Lesion of sensory
root.
Loss of sensation
of half Face
+
Ipsilateral half of body
Opposite thalamus
71
Loss of sensation
of half Face
+
opposite half of
body
Brain stem
or
Opposite thalamus
69. TOTAL SENSORY LOSS OVER ONE
OR TWO OF MAIN DIVISION
Causes –
1. Partial lesion of ganglion (HZV)
2. Trauma
3. Cavernous sinus syndrome
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70. ONLY TOUCH IS LOST
Pontine lesion affecting chief sensory nucleus.
causes –
1. Vascular diseases
2. Pontine tumor
3. Brain stem displacement d
due to large tumor
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71. LOSS OF PAIN AND TEMOPERATURE BUT TOUCH
IS SAVED
Causes –
lesions of descending root due
to
1. syringobulbia
2. foramen magnum tumor
3. bulbar vascular accidents
In case of anomalous development or occlusion of
posterior inferior cerebellar artery –
loss of pain & temperature in
- ipsilateral half face
- contralateral opposite half of body
74
72. HYPERAESTHESIA OVER ALL OR A PART OF
DISTRIBUTION OF NERVE
Causes –
1. Vascular lesion
2. Multiple sclerosis
3. Herpes infection
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74. Ninth cranial nerve.
Mixed nerve.
Motor root-basal plate of
the embryonic medulla oblongata.
Sensory root-cranial neural
crest.
Nerve of III branchial arch
77
Origin
76. Deep to
styloid pr0cess 79
Between internal and external
carotid arteries at posterior
border of stylopharyngeus
Reaches pharynx-between
middle and inferior constrictor,
deep to hypoglossus.
82. Functions of various branches of IX cranial
nerve
Auriculotemporal nerve
provides various sensory
innervations on the side of
head.
Baroreceptors are maintains
blood pressure.
Chemoreceptors are
maintains chemical
concentrations in blood.
85
83. Tonsil produce antibodies to kill
germs and help to prevent
throat and lung infections.
Soft palate is responsible for
closing of the nasal passage
during act of swallowing and
also for closing of the airway.
Stylopharyngeous muscle
elevates both pharynx and
larynx
86
85. Glossopharyngeal neuralgia
Similar to trigeminal neuralgia except the location.
Pain is present on tonsil and ear.
Pain is radiating from throat to ear because of
tympanic branch of IX nerve.
It is two types 1.Classical 2.Symptomatic
Classical type is obtained by arterial compression
of the nerve at courses through jugular foramen
Symptomatic type is obtain by under lying cause
such as oropharyngeal tumors pagetic bone or
calcified stylohyoid ligament.
88
86. Clinical features
Rarely bilateral involvement.
Episodic pain ,sharp, lancinating, and extreme intense.
Pain during talking ,chewing, yawning,
swallowing, touching a blunt instrument to tonsil.
No definite trigger zone.
Pt difficulty to localize the pain in oropharynx
Diagnosis
MRI scan of head
CT scan of head
X rays of arteries with dye( conventional angiography)
89
88. Vagus nerve
Two branches from the superior
ganglion :-
1- meningeal branch ( sensory )
2- auricular branch ( sensory )
Inferior ganglion have cells
for
GVA and SVA.
91
leave Medulla between olive and ICP.
Exit the skull through jugular foramina in
which the nerve lie posteriorly in it.
89. Anatomy
Descend in neck in the carotid sheath posteriorly
and enter thorax anterior to subclavian artery on
left and between CCA and subcalvian artery on
right side.
In mediastinum it will give branches to pulmonary
and esophageal plexus.
Enter abdomen through esophageal opening( left
anteriorly and right posteriorly ) to terminate in the
abdominal viscera.
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91. Vagus nuleus
N. ambiguous
Dorsal vagus nucleus
Nucleus solitaries
Spinal nucleus and tract
The dorsal nucleus of vagus nerve —
which sends parasympathetic output to the
viscera, especially the intestines
The nucleus ambiguus — which gives rise
to the branchial efferent motor fibers of
the vagus nerve and preganglionic
parasympathetic neurons that
innervate the heart
The solitary nucleus which receives
afferent taste information and primary
afferents from visceral organs
The spinal trigeminal nucleus which
receives information about deep/crude
touch, pain, and temperature of the outer
ear, the dura of the posterior cranial fossa
and the mucosa of the larynx
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92. Branches in H&N
In jugular fossa :-
Meningeal branch to dura of posterior
cranial cavity
Auricular branch
In neck :-
1. Pharyngeal branch :- supply all
muscles of pharynx and soft palate
except for stylopharungeous ( IX ) and
tensor veli palatine (V) { form pharungeal
plexus with IX and external laryngeal
nerve }
2.Superior laryngeal nerve divides into
external laryngeal n.and internal
laryngeal n.
3.Recurrent laryngeal
4.Cardiac branch
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93. Applied aspect
Recurrent laryngeal nerve palsies are most commonly due to malignant
disease (25%) and surgical damage (20%) during operations on the
thyroid gland, neck, oesophagus, heart and lung
Because of its longer course, lesions of the left nerve are much more
frequent than those of the right.
In a complete unilateral paralysis of vocal cords, the cord takes up an
intermediate position between full abduction and adduction; the voice
is hoarse and the patient cannot cough in the usual explosive manner.
In an incomplete lesion the cord takes up an adducted position, i.e. the
power of abduction seems to be lost first. Despite several theories,
there is no universally acceptable explanation why this should be so.
High lesions of the vagus nerve which affect the pharyngeal and
superior laryngeal as well as the recur rent laryngeal branches cause
difficulty in swallowing as well as vocal cord defects
96
94. 97
High lesions of the vagus nerve which affect the pharyngeal and
superior laryngeal as well as the recur rent laryngeal branches
cause difficulty in swallowing as well as vocal cord defects
97. References
B.D. Chaurasia :human anatomy vol3.head and neck ,5th
edition
Shafer’s Textbook of Oral Pathology
Gray’s anatomy- anatomic basis of clinical practice, 40th
edition
Malamed. Handbook of local anesthesia. 5th edition.
Elsevier.
Snells anatomy
Agbaje J O, Casteele E V , Hiel M Verbaanderd C.
Neuropathy of Trigeminal Nerve Branches After Oral and
Maxillofacial Treatment. J. Maxillofac. Oral Surg.
Daniel M. Laskin : Oral and Maxillofacial Surgery.
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