Contents DEFINITIONS TRIGEMINAL NERVE EMBRYOLOGY NUCLEI FUNCTIONAL COMPONENTS GANGLION COURSE AND RELATION BRANCHES CLINICAL EXAMINATION APPLIED ANATOMY CONCLUSION REFERENCES

1. 1

2. PRESENTED BY –
DR. KUMARI KALPANA
PG I
DEPARTMENT OF PROSTHODONTICS
2

3. 3

4. DEFINITIONS
TRIGEMINAL NERVE
EMBRYOLOGY
NUCLEI
FUNCTIONAL COMPONENTS
GANGLION
4

5. COURSE AND RELATION
BRANCHES
CLINICAL EXAMINATION
APPLIED ANATOMY
CONCLUSION
REFERENCES
5

6. 6

7. NERVE1 – it is a cord like structure made up of a collection of
fibres that convey impulse between a part of central nervous
system & some other region of the body.
71.Dorlands illustrated medical dictionary. 32nd ed. Elsevier publishers;

8. Neuron 2 -It is defined as the structural and functional unit of nervous system
2 .Hall JE, Guyton AC. Textbook of medical physiology. Pennsylvania: Elsevier publishers; 1956 .

9. Ganglion1 – A group of nerve cell bodies located outside the central nervous system,ocassionally
applied to the certain nuclear groups within the brain.
91.Dorlands illustrated medical dictionary. 32nd ed. Elsevier publishers;

10. Neuroglia1 – Supporting cell of the nervous system. It consist of fine web of
tissue made up of modified ectodermal elements in which, are enclosed
peculiar branched cells known as glial cells.
101.Dorlands illustrated medical dictionary. 32nd ed. . Elsevier publishers;

11. Sensory Nerve Fibres1 : any neuron conducting a nerve impulse that originated at a
receptor and is proceeding towards the centre. These nerve fibres are also
known as afferent nerve fibres
111.Dorlands illustrated medical dictionary. 32nd ed. . Elsevier publishers;

12. Motor Nerve Fibres1 - Motor
nerve fibers carry motor
impulses from central
nervous system to different
parts of the body.
Or
Any neuron conducting
nerve impulse that
originated at the center and
is proceeding towards the
periphery. These nerve
fibers are also called efferent
nerve fibers
12
1.Dorlands illustrated medical dictionary. 32nd ed. Elsevier publishers;

13. Mixed nerves2 contain both afferent and efferent axons, and thus conduct both
incoming sensory information and outgoing muscle commands in the same bundle
132.Hall JE, Guyton AC. Textbook of medical physiology. Pennsylvania: Elsevier publishers;

14. CRANIAL NERVES3
143. Stanley F. Malamed Handbook of Local Anaesthesia . 6th ed. Elsvier Publishers;

15. Trigeminal Nerve 4-6
N.Trigeminus ; Fifth or Trifacial Nerve
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.
15

16. This is the fifth & largest cranial nerve
It is Mixed Cranial Nerve –
- large sensory
- small motor
It emerges from lateral side of pons, near its upper border, by a small
motor root and a large sensory root-former being situated in front and
medial to the latter. These two roots enter the middle cranial fossa.
16

17. ORIGIN
17

18. EMBRYOLOGY7-8
7. Saddler TW. Langman’s medical embryology. 7th ed. Baltimore: Williams & Wilkins; 1995.
8. Singh IB, Pal GP. Human embryology. 7th ed. Delhi: Macmillan India Limited; 2001.
18

19. 19
Neural development is one of the earliest
systems to begin and the last to be
completed after birth.
In embryonic development, the trigeminal
ganglia (CN V, historically the semilunar
ganglion, Gasser's ganglion or Gasserian
ganglion) is the first to become apparent and is
the largest of the cranial nerves.

20.  By the 5th week of development, nuclei of all
the cranial nerves have appeared.
Nerve is derived from the first pharyngeal
arch.
Cells from ectodermal placodes together with
neural crest forms neurons of the 5th ,7th ,9th
and 10th cranial sensory ganglia.
20

21. 21

22. NUCLEI4-6
22
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

23. Nuclei of trigeminal nerve
NUCLEI
MOTOR
MESENCEPH-
-ALIC
SENSORY
SPINAL
23

24. 24

25. FUNCTIONAL COMPONENTS4,5
The efferent fibers classified
as special visceral efferent (SVE)
The afferent fibers
classified as general
somatic afferent (GSA)
25
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;

26. General somatic afferent fibres (GSA) conveys both
exteroceptive (touch, pain and thermal senses) and
proprioceptive (deep pressure and kinesthesis) impulses
EXTEROCEPTIVE
Skin of face and forehead
Mucous membrane of nasal cavities,
oral cavities, nasal sinuses and floor of
mouth
The teeth
Anterior 2/3rd of tongue
Extensive portions of cranial dura
PROPRIOCEPTIVE
Teeth
Peridontium
Hard palate
TMJ receptors
Stretch receptors in muscles of
mastication
26

27. SVE (branchiomotor) provides innervation to the
27
Tensor tympani

28. TRIGEMINAL GANGLION4,5,6
Ganglion Semilunar
[Gasseri] OR
Gasserian ganglion)
28
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

29. Ganglion is placed in a
depression called “trigeminal
impression” near apex of the
petrous part of the temporal
bone.
Ganglion is enclosed within a
pouch like recess of dura mater
called trigeminal cave.
29

30. Occupies a cavity (cavum meckeli) in
the dura mater.
Crescent in shape.
Convex border facing anterolaterally;
and
A Concave border facing
posteromedially.
3 division emerge from convexity
The Convex Border continues with
• Ophthalmic,
• Maxillary and
• Mandibular nerves; while
the Concave posterior border
continues with the sensory root.
303.Stanley F. Malamed Handbook of Local Anesthesia. 6th ed. Elsevier Publishers; p. 172

31. BRANCHES AND COURSE4,5,6
31
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

32. 32

33. OPHTHALMIC NERVE (V1)4-6
33
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

34. 34

35. 35

36. 1. LACRIMAL NERVE
(N.lacrimalis)
• Smallest of all three branches.
Passes into the orbit at the lateral
angle of superior orbital fissure
courses into anterolateral direction
to reach the lacrimal gland
36

37. Supplies:-
• Lateral part of the upper
eyelid & a small adjacent
area of skin next to the
eyelid laterally.
• Lacrimal gland.
37

38. 2. FRONTAL NERVE
(N. frontalis)
• Traverses anteriorly into the orbit.
• Largest of all three.
• At middle 3rd of orbit divides into:-
38

39. • Supra orbital (n. supraorbitalis) :- supplies
skin of the upper eyelid, the forehead and
the anterior scalp region to the vertex of
the skull.
• Supra trochlear (n. supratrochlearis), :-
supplies skin of the upper eyelid and lower
medial portion of the forehead.
39

40. 3.NASOCILIARY
NERVE
(N. nasociliaris;
nasal nerve)
40

41. BRANCHES OF NASOCILIARY NERVE
• LONG ROOT OF CILIARY GANGLION :
• sensory fibers to the eyeball
• LONG CILIARY NERVES :
• iris and cornea
• POSTERIOR ETHMOIDAL NERVE:
• mucous membrane lining the ethmoidal cells & sphenoid sinus
• ANTERIOR ETHMOIODAL NERVE
• (a) internal nasal branch
• (b) external nasal branch : skin over the tip of the nose & ala of
the nose.
BRANCHES IN THE ORBIT
41

42. BRANCHES
ARISING IN THE
NASAL CAVITY
Supplies the mucus
membrane lining the cavity.
42

43. • Supply sensory fibres to the skin of
the medial parts of both the eyelids.
• Lacrimal sac
• Lacrimal carbuncle
• Skin over the side of the bridge of
the nose.
TERMINAL BRANCHES
OF THE OPTHALMIC
DIVISIONS ON THE
FACE
43

44. GANGLION ASSOCIATED : CILIARY GANGLION4,5,6
(OPTHALMIC GANGLION)
44
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

45. Three
roots
Motor
root
Derived from
nasocilliary nerve
Sensory
root
Sympathetic
nerve
may come from
sensory root or
directly from the
internal carotid
plexus.
Carries preganglionic
parasympathetic
fibres.
45

46. MAXILLARY NERVE4-6
46
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

47. MAXILLARY NERVE(V2)
(N. maxillaris; superior maxillary nerve)
47

48. MANDIBULAR NERVE4-6
(n. mandibularis ; inferior maxillary nerve)
48
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors;
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.

49. MANDIBULAR NERVE
Largest division of trigeminal nerve
Consists of:
SENSORY ROOT (large)
The sensory root arises from the
semilunar ganglion.
MOTOR ROOT (small)
These are derived from the motor cells
located in the medulla oblongata.
49

50. 50
The motor root is located in the
middle cranial fossa. It joins the
sensory root after the latter leaves
the semilunar ganglion.
The two roots pass side by side in
the dura of the middle cranial fossa
to the foramen ovale.
Leaving the foramen it unites to
form a single trunk

51. Sensory supply:
•Mucous membranes and floor of the oral cavity
• External ear
•Lower lip
•Chin
•Anterior 2/3 of the tongue (only general
sensation; special taste sensation supplied by
the chorda tympani, a branch of the facial
nerve)
•Lower molar, incisor and canine teeth and the
associated gingiva
51

52. Motor Supply:
•Muscles of mastication :
medial pterygoid,
lateral pterygoid,
masseter,
Temporalis
•Anterior belly of the digastric muscle and
•the mylohyoid muscle
•Tensor veli palatini
•Tensor tympani
52

53. 53

54. 54

55. 1. MENINGEAL BRANCH- (nervous spinosus)
SUPPLIES:
 Dura mater in the middle cranial fossa & to a lesser extent in the
anterior cranial fossa.
 Contains sympathetic postganglionic fibres from the middle meningeal
plexus.
2. NERVE TO MEDIAL PTERYGOID
SUPPLIES:
 Medial pterygoid muscle.
 Some fibres pass through the otic ganglion without interruption to supply
the tensor tympani & the tensor veli palatini.
55

56. ANTERIOR TRUNK
1. BUCCAL NERVE
SUPPLIES:
1.The skin over the anterior part of the
buccinator & the buccal mucous membrane.
2.Posterior part of the buccal gingivae
adjacent to the lower second & third
molars.
2. MASSETERIC NERVE
SUPPLIES:
• Masseter muscle.
• Temporomandibular joint.
56

57. 3. DEEP TEMPORAL NERVES
SUPPLIES:
temporalis muscle
4. NERVE TO LATERAL
PTERYGOID
SUPPLIES:
1. Lateral pterygoid muscle
57

58. 3. POSTERIOR TRUNK
Mainly sensory but few filaments from motor
root for the nerve to mylohyoid
58

59. 59
Auriculotemporal nerve

60. 60
AURICULOTEMPORAL NERVE
BRANCHES & ITS SUPPLIES:
1 ANTERIOR AURICULAR:- skin of the tragus & a small part adjoining
helix
2 BRANCH TO EXTERNAL ACOUSTIC MEATUS:- skin of meatus &
tympanic membrane
3. ARTICULAR:- temporomandibular joint
4. PAROTID:- postganglionic secretomotor fibres
5. SUPERFICIAL TEMPORAL BRANCHES:- skin of the temporal region

61. 61
Lingual Nerve

62. 62

63. GANGLIONS ASSOCIATED
SUBMANDIBULAR
GANGLION
OTIC GANGLION
63

64. 64

65. 1. SUBMANDIBULAR (SUB MAXILLARY) GANGLION
 The submandibular gland is a small ovoid body suspended from the lingual nerve
above the submandibular salivary gland.
 Supplies secretomotor fibres to the sub mandibular gland.
65

66. 2.Otic ganglion (ganglion oticum)
It is a peripheral parasympathetic ganglion which relay
secretomotor fibres to the parotid gland.
It is 2 to 3 mm in size situated in infratemporal fossa below
the foramen ovale medial to mandibular nerve, lateral to tensor
veli palatini.
66

68. EXAMINATION OF TRIGEMINAL NERVE
68

69. 69

70. APPLIED ANATOMY:
EFFECTS OF NERVE INJURY AND
DISEASES
70

71. OPHTHALAMIC BRANCH
71
The corneal reflex, also known as the blink reflex, is an
involuntary blinking of the eyelids elicited by stimulation
of the cornea.
The reflex occurs at a rapid rate of 0.1 seconds.

72. 72
The reflex is mediated by:
the nasociliary branch of the ophthalmic branch (V1) of the 5th
cranial nerve (trigeminal nerve) sensing the stimulus on the cornea
only (afferent fiber).
There is loss of corneal blink reflex if the ophthalmic nerve is
paralyzed.

73. 73

74. 74
Conservative management can be divided into
three broad categories including
• lubrication,
• retaining moisture,
• improvement of tear quality

75. 75
Aggressive lubrication of the ocular surface includes
the administration of artificial tears in mild cases
and thicker lubricating gels or ointments for more
severe cases. Ointment can be placed on the eye at
bedtime to prevent corneal exposure.
Retention of moisture can be obtained by room air
humidifiers, turning off fans in the environment,
wearing humidification goggles

76. MAXILLARY BRANCH
o Fractures of body of the zygomatic
complex--- infraorbital nerve-- neuropraxia
and neurotmesis
o Zygomatic nerve damage caused during
anesthesia---can cause anesthesia of temple,
cheek, one side of the upper lip and side of
the nose.
76

77. 77
 In severely
Atrophied bone long
fixtures cannot be
placed without
encroaching on IAN.
 One of the option is
Inferior Alveolar
Nerve Repositioning
(IANR).24
24. Abayev B, Juodzbalys G. Inferior alveolar nerve lateralization and transposition for dental implant placement part I : a
systematic review of surgical techniques. J oral Maxillofac Res 2015 (Jan-Mar);6(1):1-13

78. 78
24. Abayev B, Juodzbalys G. Inferior alveolar nerve lateralization and transposition for dental implant placement part I : a
Two Inferior alveolar nerve repositioning
techniques have been developed
Inferior Alveolar
Nerve
Laterization
Inferior Alveolar
Nerve
Transposition

79. 79
24. Abayev B, Juodzbalys G. Inferior alveolar nerve lateralization and transposition for dental implant placement part I : a
1.Buccal/Lateral bone window 1. Buccal/lateral bone window
2.Partial osteotomy of mental foramen distal portion. 2. Complete osteotomy of the mental
foramen.
3. Maintaining the integrity of the incisive nerve. 3. Micro-dissection of the IAN
4. Gentle buccal traction of the IAN 4. Incision of the incisive nerve.
5. Replacement of the IAN on the implant surface (with
collagen and PRF [platelet rich fibrin] protective layer)
5. Repositioning of the IAN
6. Incorporation of the IAN into buccal flap Incorporation of the IAN into buccal flap
IAN Laterization IAN Transposition

80. 80
24. Abayev B, Juodzbalys G. Inferior alveolar nerve lateralization and transposition for dental implant placement part I : a
systematic review of surgical techniques. J oral Maxillofac Res 2015 (Jan-Mar);6(1)
Drawing showing the Inferior alveolar neurovascular bundle transposition (A) Transposition
(B) Lateralization.

81. Mandibular branch9,10
 Gustatory Sweating
and Flushing (Frey’s-
Baillarger
syndrome/Dupuy’s
syndrome/auriculotem
poral syndromes)-
3rd molar area-most
common site of injury
81
9. Rajiv M. Borle textbook of oral & maxillofacial surgery. jaypee publishers; pg 162
10. F Prattico, P Perfetti. N Engl J Med. 2006 Jul 6:355(1):66

82. Injury to the auriculotemporal nerve at the condylar neck
area
denervates the sweat glands, vessels of the skin over its
distribution, sensory disturbances.
gustatory stimulus produces sweating and flushing.
develops about 5 or more weeks after injury
82

83. 10.Prattico F, M.D., A Perfetti P, M.D. N Engl J Med 2006. 83

84. 84

85. Lingual nerve damage-loss of
sensation in the anterior two third of
the tongue
The lingual nerve may also be kinked
at the pterygo-mandibular raphe or
under-run with a suture
85

86. 86

87. Trigeminal Neuralgia’ refers to sudden,usually
unilateral, severe, brief, stabbing, lancinating,
paroxysmal, recurring pain in the distribution of
one or more branches of the trigeminal nerve.
Nicholas Andre in 1956 coined the term ‘’Tic
Douloureux’’ i.e. painfull jerking
87

88. 88
a) Patient photograph during the attack of trigeminal neuralgia pain
b) Patient after the diagnostic injection of local anaesthetic agent.

89. Etiology11-15
1. Idiopathic
2. Benign tumors that can Compress the trigeminal nerve
3. Vascular factors
4. Mechanical factors
89
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD; 2015.
12.Neville BW, damm dd, allen MC, Bouquot JE. Oral & Maxillofacial Pathology. 3RD Ed. Elsvier publishers; 2008.
13.Peterson LJ. Contemporary Oral & Maxillofacial Surgery. 5TH Ed. Elsvier publishers; 2018.
14. Burket LW. Burket’s Oral medicine. 11th ed. Pmph USA; 2008.
15.Shafer STR. Shaefer’s Textbook of Oral Pathology. 6ed. Elsevier publisher; 2009.

90. 5. Anomaly of the Superior Cerebellar artery
6. Infections
7. Multiple Sclerosis
8. Post traumatic Neuralgia
90

91. CLASSIFICATION OF
TRIGEMINAL NEURALGIA11
9111. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD;

92. I According to the latest classification of the International
Headache Society (on the basis of the symptoms):
Classical TN (CTN)
• idiopathic, potentially vascular compression .
• classic pain and definite periods of remission .
• pain- intensely sharp, throbbing and shock- like, usually triggered by
touching an area of the skin or by specific activities.
• No clinical evident neurological deficit
92

93. 93
Symptomatic TN (STN)
• secondary to tumour,
• Multiple Sclerosis,
• structural abnormalities of the skull base
• no remission period, symptoms more difficult to
treat
• pain-constant, burning sensation affecting a more
widespread area of the face.

94. II. Seven types of face pains ( Acc to Dr. Burchiel)16
• Trigeminal neuralgia, type 1, (TN1): facial pain of spontaneous onset
with greater than 50% limited to the duration of an episode of pain
(temporary pain).
16. A new Classification of facial pain : A patient oriented classification scheme for facial pains. [Online]. 3rd May 2011.
Available from :
URL: http://www.fpa-support.org/2011/05/a-new-classification-of-facial-pain-a-patient-oriented-classification-scheme-for-
facial-pains-2/
. Trigeminal neuralgia, type 2, (TN2): facial pain of spontaneous onset
with greater than 50% as a constant pain.
94

95. 95
• Trigeminal neuropathic pain, (TNP): facial pain resulting from
unintentional injury to the trigeminal system from facial trauma,
oral surgery, ear, nose and throat (ENT) etc.
• Trigeminal differentiation pain, (TDP): facial pain in a region of
trigeminal numbness resulting from intentional injury to the
neurectomy, gangliolysis, rhizotomy, nucleotomy or other
denervating procedures.

96. • Symptomatic trigeminal neuralgia, (STN): pain resulting from multiple
sclerosis.
• Postherpetic neuralgia, (PHN):pain resulting from trigeminal Herpes
zoster outbreak. (SHINGLES).
• Atypical facial pain, (AFP): is facial pain of unknown origin.
96

97. GENERAL
CHARACTERISTICS11-15
97
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD;.
12.Neville BW, damm dd, allen MC, Bouquot JE. Oral & Maxillofacial Pathology. 3RD Ed. Elsvier publishers; 2008.
13.Peterson LJ. Contemporary Oral & Maxillofacial Surgery. 5TH Ed. Elsvier publishers; 2018.
14. Burket LW. Burket’s Oral medicine. 11th ed. Pmph USA; 2008.
15.Shafer STR. Shaefer’s Textbook of Oral Pathology. 6ed. Elsevier publisher; 2009.

98. 98
Incidence :
4 in 1,00,000 persons11
6 in 100,000 persons12
8 in 100,000 persons13
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi; Jaypee Brothers Medical Publishers(P)LTD: p. 764-768
12.Neville, Damm DD, Allen MC, Bouquot JE. Oral& maxillofacial pathology. 3RD Ed. Elsevier publishers; p. 861-863
13.Peterson LJ, Contemporary oral & maxillofacial surgery. 5TH Edition ,Elsevier publishers,621-622.

99. 99
The total lifetime prevalence of trigeminal neuralgia in people ages
18–65 years ranged from 0.1% in Norway to 0.3% in Germany.25
Global Data epidemiologists forecast that the
diagnosed incident cases of trigeminal
neuralgia in the US will grow at 16.70% over
the next decade, from 98,804 cases in 2012 to
115,275 cases in 2022.
25. Mueller D, Obermann M, Yoon M-S, Hansen N, Slomke M-A et al. Prevalence of trigeminal neuralgia and persistent
idiopathic facial pain: a population based study. Cephalgia. 2011 Nov; 31(15);1542-8

100. 100
• A study was conducted in the Dept. of Oral & Maxillofacial surgery, PDM
dental college, Haryana, India where 72 cases were reported for the idiopathic
trigeminal neuralgia during November 2009 to November 2010 who were
regularly followed up for a minimum of 3 years .
• The data was perceived & it was analyzed that the mean age was 54.9 years &
female to male ratio was 2.13:1, rural to urban ration is 1.76:1 with 62.5%
suffered trigeminal neuralgic pain on the right side.
Yadav.S et.al. A retrospective study of 72 cases diagnosed with idiopathic trigeminal neuralgia in indian populace; J Clin Exp Dent.
2015:7(1):40-4.

101. 101
 Age of occurrence : 5th or 6th decade of life
 Sex predilection : ♀ > ♂
female to male ratio 1.6:113
female to male ratio – 3 :215
13.PETERSON LJ. CONTEMPORARY ORAL & MAXILLOFACIAL SURGERY. 5TH ED. ELSVIER PUBLISHERS;
15.SHAEFER’S TEXTBOOK OF ORAL PATHOLOG.

102. 102
 Affliction for site : right>left : 1.7:115
 Division of trigeminal nerve involvement :
V3>V2>V113,14
V2>V3>V115
12.NEVILLE.BW, DAMM DD, ALLEN MC, BOUQUOT JE. ORAL& MAXILLOFACIAL PATHOLOGY. 3RD Ed. ELSVIER PUBLISHERS;
13.PETERSON LJ. CONTEMPORARY ORAL & MAXILLOFACIAL SURGERY. 5TH ED. ELSVIER PUBLISHERS;
14.BURKET’S ORAL MEDICINE. 11TH Ed. CBS PUBLISHERS;
15.SHAEFER’S TEXTBOOK OF ORAL PATHOLOG.

103. 103
CLINICAL
FEATURES12-15
12.NEVILLE.BW, DAMM DD, ALLEN MC, BOUQUOT JE. ORAL& MAXILLOFACIAL PATHOLOGY. 3RD Ed. ELSVIER PUBLISHERS;
13.PETERSON LJ. CONTEMPORARY ORAL & MAXILLOFACIAL SURGERY. 5TH ED. ELSVIER PUBLISHERS;
14.BURKET’S ORAL MEDICINE. 11TH Ed. CBS PUBLISHERS;
15.SHAEFER’S TEXTBOOK OF ORAL PATHOLOG.

104. CLINICAL FEATURES
• sudden, unilateral, intermittent paroxysmal, sharp, shooting,
lancinating, shock like pain, elicited by slight touching
superficial trigger points which radiates from that point,
across the distribution of one or more branches of the
trigeminal nerve
104

105. • Pain is usually confined to one part of one division of trigeminal
nerve and rarely involve all the three divisions.
• Pain rarely crosses the midline.
• The duration of single pain spasm” is less than 2 minutes, although the
overall attack may consist of numerous repeating spasms of short
duration.
• For several minutes after an attack ( the refractory period) touching
the trigger point usually cannot induce additional attacks.
105

106. 106
• The pain may be so severe that the patient lives in
constant fear of an attack, and many sufferers have
attempted suicide to put an end to their torment.
• The pain is dramatical, diminished, atleast initially, with
the use of carbamazepine.
• Spontaneous remissions may occur, often lasting more
than 6 months, especially during the early phase of the
disease.
.

107. Trigger zone
The areas on the facial skin or oral mucosa where even the low intensity
mechanical stimulation such as
o light touch,
o an air puff,
o or even touching face,
o by chewing or
o even by speaking or smiling,
o brushing, shaving or even washing the face
can elicit the pain.
107

108. IN MAXILLARY DIVISION – skin of the upper lip ,
ala , nasi , or cheek or on the upper gums.
IN MANDIBULAR DIVISION – lower lip , teeth or
gums of the lower jaw , tongue(rare).
IN OPHTHALMIC DIVISION – supraorbital ridge on
affected side.
Trigger points
108

109. INTRA ORAL TRIGGER POINTS17
An introral trigger point can make the diagnosis of
trigeminal neuralgia difficult because the dental
practitioner must eliminate the odontogenic etiology.
109
17.Fabiano J, Fabiano A, Patricks A, Thines Terrence. Trigeminal Neuralgia with intraoral trigger points. SpecCare Dentist. 2005
jul;(4):206-2013

110. • Fabiano et al reported a case in which a 74yr old patient came to a
general practitioner with a complaint of irritation of the lower right
lip and right side of tongue and a sharp pain that occurred when
either her tongue or lip(or both)touched the lower denture and this
pain occurred even when the denture was not in the mouth.
110
17.Fabiano J, Fabiano A, Patricks A, Thines Terrence. Trigeminal Neuralgia with intraoral trigger points. SpecCare Dentist;
2005;206-2013

111. 111
After thorough examination and ruling out all the differential
diagnosis he concluded that not only a peri-oral but also an
intra oral trigger can elicit the pain of trigeminal neuralgia.
17.Fabiano J, Fabiano A, Patricks A, Thines Terrence. Trigeminal Neuralgia with intraoral trigger points. SpecCare Dentist;
2005;206-2013a

112. DIAGNOSIS
1. Sweet diagnostic criteria
• published by IASP(International Association for the
study of pain) & HIS(International Headache Society)
112

113. 5 major criteria for TN
 Pain is paroxysmal
 pain may be provoked by light touch
to the face (trigger zones)
 pain is confined to the trigeminal distribution
 pain is unilateral
 The clinical sensory examination is normal
113

114. DIFFERENTIAL DIAGNOSIS
1.Dental pain
.
3.Glossopharyngeal neuralgia
114
2.Sphenopalatine neuralgia
4.Migraine

115. 6.Multiple sclerosis
7. Post Herpetic neuralgia
8. SUNCT.
115

116. POST-HERPETIC NEURALGIA
stages
Prodormal stage-
burning,itching,tingling
sensation
Active stage-
rash accompanied by
fever,malaise,headache,
low grade fever
Chronic stage(PHN)-
pain lasting beyond the
period of healing of active
skin lesions
116

117. • Ocular involvement – most commonly
involved
• Itching, tingling or pain sensation in the rash.
• Burning and tingling sensation
(paresthesia/dysesthesia) in the affected side
of face, including oral cavity.
• Sharp, shooting pain in response to light
touches (allodynia).
20. J can dent assoc 2014;80:e42
117

118. 118
• Prolonged or exaggerated response to
painful sensation
(hyperalgesia/hyperesthesia).
• Odontogenic pain owing to maxillary (V2)
and mandibular (V3) nerve division.
• Rare and serious complication-
spontaneous tooth exfoliation and
necrosis of the mandible.

119. Anti-viral drug therapy
- Acyclovir(800mg qid for 10days)
- Famciclovir(500mg every 8hr for
7days)
- Valacyclovir(1g tid for 7days)
119

120. SUNCT SYNDROME22
“ Short lasting Unilateral Neuralgiform
headache with Conjuctival injection and
tearing”
Clinical manifestations
(a) brief attacks of moderate to severe
pain
(b) conjuctival injection, lacrimation,
rhinorrhoea or nasal congestion, ptosis, or eyelid
edema
22. Panconesi A, Bartolozzi ML, Guidi L. SUNCT syndrome or first division trigeminal neuralgia associated with cerebellar
hypoplasia. J Headache Pain 2009;10:461-64
120

121. (C) site of pain can be unilateral orbital, supraorbital or temporal pain
(d) burning, pricking, or electric shock-like pain sensation.
(e) triggers include touching the face, chewing, talking, or cold wind on
the face.
121

122. Patient isolation
• The skin- Open wet dressings followed by lotions. Gauze or a face cloth
soaked in cool water and applied to the rash area for 30min 3-6 times a day.
• Pain-Mild to moderate strong analgesics, such as acetaminophen, codeine and
NSAIDs are effective.
MANAGEMENT
122

123. 123
 TREATMENT
Carbamazepine- upto 900mg daily
Lamotrigine-300mg daily
Gabapentin-800-2700mg daily
Topiramate – upto 300mg daily

124. 124

125. MEDICATIONS TOPICAL PREPARATIONS FOR ORAL
AND PERIORAL USE
MECHANISM OF
ACTION
TOPICAL
ANAESTHETICS
1. Benzocaine in Orabase
(20%) for intraoral use only
2. Lidocaine gel, for intra-oral use
only
3. Eutectic mixture of local
aesthetic (emla )cream ,for intra-
oral n extra oral use
Sodium Channel
Blockade
NEUROPEPTIDE:
CAPSAICIN
Cream in 0.025%and 0.075%
strengths (for intraoral and
extraoral use)
Inhibition of peripheral
nociceptor terminal
function
125

126. NONSTEROIDAL
ANTI-INFLAMMATORY
DRUGS
1.Ketoprofen (10-20%)in an
organo gel ,for extra-
oral use only
2. Diclofenac (10-20%)
in an organo gel,for extra
oral use only
Blocks prostaglandin
production
through cyclooxygenase
inhibition
SYMPATHOMIMETIC
AGENTS:
CLONIDINE
1. Patch (for extraoral
useonly)
2. 0.01% base(for
intraoral use only)
Influences peripheral alpha
adrenergic activity
ANTICONVULSANTS Carbamazepine (2%) in a
base(for extraoral use only)
Blocks ase-dependent
sodium
channel activity
126

127. DRUGS DOSES SIDE EFFECTS
Carbamazepine
(tegretol)
100mg bid Visual blurring, dizziness,
skin rashes,
thrombocytopenia
Phenytoin (dilantin) 100mg tid Slurred speech, gingival
hypertrophy,
hirusitism,folate deficiency
Clonazepam
(clonafit)
0.5mg tid Drowsiness, fatigue,
lethargy
Gabapentin
(gabapin)
300mg tid Fatigue, dizziness
Baclofen(lioresal) 5mgtid Fatigue and vomiting
127

128. MICROVASCULAR
DECOMPRESSION
SENSORY RHIZOTOMY
BALLOON COMPRESSION
PERIPHERAL
NEUROECTOMY
RADIO FREQUENCY
RHIZOTOMY
SURGICAL
MANAGEMENT11
12811. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD;

129. PERCUTANEOUS PROCEDURES
Percutaneous retrogasserian glycerol rhizotomy
Needle is inserted contrast(dye) is introduced glycerol is added
129

130. Gamma knife surgery
Head frame attachment to
Pinpoint the target area with
High accuracy
Gamma-knife suite where the
head frame is attached to the
Autonomic Positioning
System(APS)
RADIATION THERAPY
130

131. Small incision made behind the
ear on the affected side
Teflon material is placed
between the nerve and the
vessel
18. Sahini k. Trigeminal neuralgia treatment center of Virginia.
SURGICAL PROCEDURES
A. MICROVASCULAR DECOMPRESSION11,18
131
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD.

132. Needle is inserted in the foramen ovale using
fluroscopic guide.
Through the needle the Fogarty catheter is
advanced until its tip lies in Meckel’s cave and
the balloon is slowly inflated
B. Balloon Compression11,19
19. Punyani S, Jasuja V. Trigeminal neuralgia:An insight into the current treatment modalities. Journal of Oral Biology
and Craniofacial Research; 2012 Sept-Dec(2):188-197;
132
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD;

133. C. Peripheral Neurectomy
An incision made at the eyebrow(supra-
orbital nerve) or intra- orally (infra-orbital,
alveolar and lingual nerves).
All branches are divided and avulsed
under magnification.
relevant foramen is blocked by bone wax,
wooden sticks or silicone plugs.
remnant of the nerve may also be
cauterized.
133

134. 1.Cryotherapy
Involved branch is exposed
frozen by direct application of a cryoprobe
with a tip temperature from -50 to -70 C
2. Alcohol Block
• Alcohol injections must be administered
directly into the nerve.
• The injections are painful and often cause
local oedema
OTHER PROCEDURES INVOLVE :
134

135. 3. ACCUPUNCTURE16
20. Kumar S et al. Treatment of resistant trigeminal neuralgia by acupuncture-a report of 3 cases. Int J Dent
2011;I(2):85-91 135

136. 4. NATURAL REMEDIES21
• Cayenne stimulates circulation and blood flow in the body. As
such, it can treat nerve pain associated with transmission of
nerve signals. It also serves as a topical pain reliever as the
capsaicin in cayenne delivers a consistent amount of heat to the
site of concern
21. Neuralgia remedies. Earth clinic[serial online]2014 Jun21. Available from:
URL: http://www.earthclinic.com/CURES/neuralgia.html
• Apple cider vinegar alkalizes the body and removes toxins that may be
contributing to pain.
• Additionally, apple cider vinegar delivers a variety of vitamins and
minerals to the body
136

137. 137
CONCLUSION

138. REFERENCES :
1.Dorlands illustrated medical dictionary. 32nd ed. Elsevier publishers.
2 .Hall JE, Guyton AC. Textbook of medical physiology. Pennsylvania: Elsevier publishers; 1956.
4. Singh IB. Anatomy for dental students. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers(P)Ltd; 2003.
5. Monheim’s. Local Anesthesia and pain control in dental practice. 7th ed. Delhi: CBS Publishers & Distributors.
6. .Gray H, William PL: Gray’s anatomy: The anatomical basis of clinical practice.34thed. London: Longman; 1967.
7.Saddler TW. Langman’s medical embryology. 7th ed. Baltimore:Williams & Wilkins; 1995.
8. Singh IB, Pal G.P. Human embryology. 7th ed. Delhi: Macmillan India Limited; 2001.
9. Borle RM. Textbook of oral & maxillofacial surgery. New delhi: Jaypee publisher; 2014.
10.F Prattico, P Perfetti. N Engl J Med. 2006 Jul 6:355(1):66
3.Stanley F. Malamed Handbook of Local Anaesthesia. 6th ed. : Elsevier Publishers.

139. 139
16. A new Classification of facial pain: A patient oriented classification scheme for facial pains [Online].
2011[may];Available from
: URL: http://www.fpa-support.org/2011/05/a-new-classification-of-facial-pain-a-patient-oriented-classification-scheme-for-
facial-pains-2/
18. Sahini K. In journal of the neurosurgery 1990 Jan 1;72:1 , 55-58.
11. Malik N. Textbook of Oral and Maxillofacial surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers(P)LTD; 2015.
12.Neville BW, damm dd, allen MC, Bouquot JE. Oral & Maxillofacial Pathology. 3RD Ed. Elsevier publishers; 2008.
13.Peterson LJ. Contemporary Oral & Maxillofacial Surgery. 5TH Ed. Elsevier publishers; 2018.
14. Burkett LW. Burkett's Oral medicine. 11th ed. Pmph USA; 2008.
15.Shafer STR. Shaefer’s Textbook of Oral Pathology. 6ed. Elsevier publisher; 2009.
17.Fabiano J, Fabiano A, Patricks A, Thines Terrence. Trigeminal Neuralgia with intraoral trigger points. SpecCare Dentist. 2005
jul;(4):206-2013.

140. 140
22. Panconesi A, Bartolozzi ml, Guidi ll. Sunct Syndrome or first division trigeminal neuralgia associated with
cerebellar hypoplasia. j headache pain 2009;(10):461-64
23. Paediatric share care programme[online]. 2003 Aug; Available from:
URL:http://www.nuh.com.sg
24. Abayev B, Juodzbalys G. Inferior alveolar nerve lateralization and transposition for dental implant placement part I
: a systematic review of surgical techniques. J oral Maxillofac Res 2015 (Jan-Mar);6(1)
25. Mueller D, Obermann M, Yoon M-S, Hansen N, Slomke M-A et al. Prevalence of trigeminal neuralgia and
persistent idiopathic facial pain: a population based study. Cephalgia. 2011 Nov; 31(15);1542-8
19. Punyani S, Jasuja V. Trigeminal neuralgia:An insight into the current treatment modalities. Journal of Oral Biology and
Craniofacial Research 2012 ;(2):188-97
20. Kumar l. Treatment of resistant trigeminal neuralgia by acupuncture-a report of 3 cases. Int J Dent case reports. 2011;I(2):85-
91
21.Neuralgia remedies [online]. 2014 [June]; Available from:
URL:http://www.earthclinic.com/CURES/neuralgia.html

141. 141