Trigeminal nerve/ dental implant courses

It is the fifth cranial nerve and largest of all cranialIt is the fifth cranial nerve and largest of all cranial
nerves.nerves.
Type: MixedType: Mixed
Functional componentsFunctional components::
Branchmotor-fibreBranchmotor-fibre supply muscles derived from firstsupply muscles derived from first
branchial arch myotomebranchial arch myotome
General somatic-fibresGeneral somatic-fibres from skin of scalp, gum, face.from skin of scalp, gum, face.
Trigeminal nerveTrigeminal nerve
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NucleusNucleus of Originof Origin
Sensory nucleusSensory nucleus:: is situated within the ponsis situated within the pons
lateral to the motor nucleus of the nerve. Itlateral to the motor nucleus of the nerve. It
receives fibres for touch sensation.receives fibres for touch sensation.
Spinal nucleusSpinal nucleus:: is situated cranially to 2is situated cranially to 2ndnd
or 3or 3rdrd
cervical spinal segments . It receives paincervical spinal segments . It receives pain
and temperature from trigeminal area andand temperature from trigeminal area and
general somatic sensations from 7general somatic sensations from 7thth
, 9, 9thth
andand
1010thth
cranial nerves.cranial nerves.

Mesencephalic nucleusMesencephalic nucleus::
situated in central grey matter of midbrain onsituated in central grey matter of midbrain on
either side of cerebral aqueduct. It receiveseither side of cerebral aqueduct. It receives
proprioceptive sensations of the 5proprioceptive sensations of the 5thth
cranial nerve.cranial nerve.
Motor nucleusMotor nucleus::
situated within pons, medial to sensory nucleussituated within pons, medial to sensory nucleus
and fibres from it form the motor root of theand fibres from it form the motor root of the
nerve. This nucleus represents the specialnerve. This nucleus represents the special
visceral efferent columnvisceral efferent column..

Superficial origin;Superficial origin;
Motor and Sensory rootMotor and Sensory root emerge from the ventralemerge from the ventral
aspect of the pons. The sensory root passes forwardaspect of the pons. The sensory root passes forward
from posterior cranial fossa and joins the posteriorfrom posterior cranial fossa and joins the posterior
margin of the Trigeminal ganglion.margin of the Trigeminal ganglion.
The motor root passes forward below theThe motor root passes forward below the
sensory root and trigeminal ganglion to join withsensory root and trigeminal ganglion to join with
sensory part of Mandibular nerve in Foramen ovalesensory part of Mandibular nerve in Foramen ovale
and form the trunk of the mandibular nerveand form the trunk of the mandibular nerve..

The Trigeminal ganglionThe Trigeminal ganglion
SynonymsSynonyms: Semilunar or Gasserian ganglion: Semilunar or Gasserian ganglion
DevelopmentDevelopment: From neural crest cells: From neural crest cells
LocationLocation: occupies a small recess in the trigeminal cave /: occupies a small recess in the trigeminal cave /
Meckel’s cavity.Meckel’s cavity.
It lies at a depth of 4.5 to 5cm from the lateral surfaceIt lies at a depth of 4.5 to 5cm from the lateral surface
of the head at the posterior end of the zygomaticof the head at the posterior end of the zygomatic
arch; it is crescentic with its convexity directedarch; it is crescentic with its convexity directed
anterolaterally and on its surface interface nerveanterolaterally and on its surface interface nerve
fascicles are visible.fascicles are visible.
Medial to it are the internal carotid arteryMedial to it are the internal carotid artery
and posterior part of cavernous sinus; interior areand posterior part of cavernous sinus; interior are
the motor root; the greater petrosal nerve; apex ofthe motor root; the greater petrosal nerve; apex of
petrous part of temporal bone and foramen lacerumpetrous part of temporal bone and foramen lacerum

Branches:Branches:
• The Opthalmic nerveThe Opthalmic nerve
• The Maxillary nerveThe Maxillary nerve
• The Mandibular nerveThe Mandibular nerve

The Opthalmic nerveThe Opthalmic nerve
It is the smallest divisions of the trigeminal nerve. It isIt is the smallest divisions of the trigeminal nerve. It is
purely sensory.purely sensory.
Origin & Course:Origin & Course: it arises from the anteriomedial end ofit arises from the anteriomedial end of
the trigeminal ganglion as a flat band, about 2.5 cmthe trigeminal ganglion as a flat band, about 2.5 cm
passing forwards in the cavernous sinus in its lateralpassing forwards in the cavernous sinus in its lateral
wall, below oculomotor and trochlear nerves just beforewall, below oculomotor and trochlear nerves just before
entering the orbit through the superior orbital fissure itentering the orbit through the superior orbital fissure it
divides into –divides into –
• Lacrimal nerveLacrimal nerve
• Frontal nerveFrontal nerve
• Nasociliary nerveNasociliary nerve

Connections:Connections:
It is joined by filaments from internal carotid sympatheticIt is joined by filaments from internal carotid sympathetic
plexus.plexus.
Communicates with oculomotor, Trochlear and abducentCommunicates with oculomotor, Trochlear and abducent
nerves.nerves.
It has Recurrent meningeal branch which crosses below andIt has Recurrent meningeal branch which crosses below and
adheres to the Trochlear nerve and is distributed toadheres to the Trochlear nerve and is distributed to
tentorium cerebellitentorium cerebelli
Branches supply-Branches supply-
• EyeballEyeball
• Lacrimal glandLacrimal gland
• ConjunctivaConjunctiva
• Part of nasal mucosaPart of nasal mucosa
• Skin of nose, eyelids, forehead and part of scalpSkin of nose, eyelids, forehead and part of scalp..

Lacrimal nerveLacrimal nerve
• It is a sensory nerveIt is a sensory nerve
• Enters the orbit through lateral part of superior orbital fissureEnters the orbit through lateral part of superior orbital fissure
runs along the upper border of rectus lateralis.runs along the upper border of rectus lateralis.
• Receives a twig from zygomatico temporal branch of maxillaryReceives a twig from zygomatico temporal branch of maxillary
nerve, it enters lacrimal gland.nerve, it enters lacrimal gland.
• It pierces the orbital septum to supply upper eyelid, joins withIt pierces the orbital septum to supply upper eyelid, joins with
filaments of facial nerve.filaments of facial nerve.
Frontal nerveFrontal nerve
CourseCourse :: It enters the orbit through lateral part of superior orbitalIt enters the orbit through lateral part of superior orbital
fissure outside the annulus tendinous communis lateral tofissure outside the annulus tendinous communis lateral to
trochlear nerve. In the orbit the nerve passes between roof oftrochlear nerve. In the orbit the nerve passes between roof of
the orbit and levator palpebrae superioris. It terminates in thethe orbit and levator palpebrae superioris. It terminates in the
midway between the base and apex of the orbit to divide intomidway between the base and apex of the orbit to divide into ––
• Supratrochlear nerveSupratrochlear nerve
• Supraorbital nerveSupraorbital nerve

Supratrochlear nerveSupratrochlear nerve
 It emerges between trochlea and supra orbital foramenIt emerges between trochlea and supra orbital foramen
curving up on foreheadcurving up on forehead
 Supplies conjunctiva, skin of the upper eyelid and lowerSupplies conjunctiva, skin of the upper eyelid and lower
part of the forehead.part of the forehead.
 It gives communicating branch to infratrochlear branch ofIt gives communicating branch to infratrochlear branch of
nasociliary nervenasociliary nerve
Supraorbital nervesSupraorbital nerves
 It ascends on forehead with the artery divides into branches toIt ascends on forehead with the artery divides into branches to
supplysupply
 Skin of the scalp upto lambdoid suture,mucous membrane of frontalSkin of the scalp upto lambdoid suture,mucous membrane of frontal
sinus and pericraniumsinus and pericranium

Nasociliary nerveNasociliary nerve
Origin and Course :Origin and Course : It arises from the opthalmic nerve in theIt arises from the opthalmic nerve in the
anterior part of cavernous sinus. It enters the orbit by passinganterior part of cavernous sinus. It enters the orbit by passing
through the middle compartment of superior orbital fissurethrough the middle compartment of superior orbital fissure
within the annulus tendinous communis and then through thewithin the annulus tendinous communis and then through the
two heads of lateral rectus muscle.two heads of lateral rectus muscle.
Within superior orbital fissureWithin superior orbital fissure:: it lies between 2 divisionsit lies between 2 divisions
of oculomotor nerve and abducent nerve lies inferolateral toof oculomotor nerve and abducent nerve lies inferolateral to
inferior ramus.inferior ramus.
Within orbitWithin orbit ::
It lies lateral to optic nerve and then crosses above it from lateralIt lies lateral to optic nerve and then crosses above it from lateral
to medial side and passes below superior rectus and superiorto medial side and passes below superior rectus and superior
oblique and moves towards the medial wall of orbit. It thenoblique and moves towards the medial wall of orbit. It then
passes through the anterior ethmoidal foramen and terminatespasses through the anterior ethmoidal foramen and terminates
by continuing as anterior ethmoidal nerve.by continuing as anterior ethmoidal nerve.

Branches ofBranches of
communication:communication:
 Sympathetic plexusSympathetic plexus
 Oculomotor nerveOculomotor nerve
 Ciliary ganglionCiliary ganglion
 Long ciliary nerves :Long ciliary nerves :
supply ciliary body, iris, corneasupply ciliary body, iris, cornea
and contains post ganglionicand contains post ganglionic
sympathetic fibres for dilatorsympathetic fibres for dilator
pupillaepupillae..
 Posterior ethmoidal :Posterior ethmoidal : itit
passes through posteriorpasses through posterior
ethmoidal foramen and supplyethmoidal foramen and supply
ethmoidal and sphenoidal airethmoidal and sphenoidal air
sinuses.sinuses. www.indiandentalacademy.comwww.indiandentalacademy.com

 Anterior ethmoidal branchAnterior ethmoidal branch:: it is a continuation ofit is a continuation of
nasociliary nerve, passes through anterior ethmoidalnasociliary nerve, passes through anterior ethmoidal
foramen, and canal enters cranial cavity and passesforamen, and canal enters cranial cavity and passes
in a groove on the upper surface of cribriform platein a groove on the upper surface of cribriform plate
and then passes through a slit at the side ofand then passes through a slit at the side of
cristagalli, it enters nasal cavity to divide into:cristagalli, it enters nasal cavity to divide into:
 Internal nasal branch-Internal nasal branch- supply mucous membrane ofsupply mucous membrane of
front part of nasal septum, anterior part of of lateralfront part of nasal septum, anterior part of of lateral
wall of nasal cavity.wall of nasal cavity.
 External nasal branch-External nasal branch- supply ala, apex and vestibulesupply ala, apex and vestibule
of the noseof the nose
 Infratrochlear nerveInfratrochlear nerve:: runs along the medial orbitalruns along the medial orbital
wall above rectus medialis, it is joined near trochleawall above rectus medialis, it is joined near trochlea
by branch of supratrochlear nerve. It leaves the orbitby branch of supratrochlear nerve. It leaves the orbit
below trochlea, to supply eyelids, side of the nosebelow trochlea, to supply eyelids, side of the nose
above medial canthus, conjunctivaabove medial canthus, conjunctiva

BranchesBranches

Maxillary nerveMaxillary nerve
Origin:Origin: from the convex aspect of trigeminal ganglion.from the convex aspect of trigeminal ganglion.
Course: it leaves the trigeminal ganglion between the opthalmicCourse: it leaves the trigeminal ganglion between the opthalmic
and mandibular divisions as a plexiform band which passesand mandibular divisions as a plexiform band which passes
horizontally forwards in the lateral wall of cavernous sinus tohorizontally forwards in the lateral wall of cavernous sinus to
traverse foramen Rotundum.traverse foramen Rotundum.
It leaves the skull by passing through foramenIt leaves the skull by passing through foramen
rotundtum and enters into Pterygopalatine fossa. From here itrotundtum and enters into Pterygopalatine fossa. From here it
inclines towards posterior surface of maxilla and enters orbitinclines towards posterior surface of maxilla and enters orbit
through inferior orbital fissure.through inferior orbital fissure.

It is then called Infraorbital nerve. It passes through infraorbital grooveIt is then called Infraorbital nerve. It passes through infraorbital groove
and canal on the floor of the orbit.and canal on the floor of the orbit.
Finally it emerges on the face through the intraorbitalFinally it emerges on the face through the intraorbital
foramen and lies under the levator labii superioris and divides into theforamen and lies under the levator labii superioris and divides into the
following branches-following branches-
Maxillary division innervation:Maxillary division innervation:
SkinSkin
 middle portion of the facemiddle portion of the face
 lower eyelidlower eyelid
 side of the nose and upper lipside of the nose and upper lip
Mucous membraneMucous membrane
 nasopharynxnasopharynx
 maxillary sinusmaxillary sinus
 soft palatesoft palate
 tonsiltonsil
 hard palatehard palate
Maxillary teeth and periodontal tissuesMaxillary teeth and periodontal tissues

BranchesBranches
The maxillary division gives off branches in four regions:The maxillary division gives off branches in four regions:
 Within the craniumWithin the cranium
 In the Pterygopalatine fossaIn the Pterygopalatine fossa
 In the Infra-orbital canalIn the Infra-orbital canal
 On the faceOn the face

Branch within theBranch within the
CraniumCranium::
After separating from theAfter separating from the
trigeminal ganglion ,thetrigeminal ganglion ,the
maxillary division gives off amaxillary division gives off a
small branch ,thesmall branch ,the MiddleMiddle
Meningeal NerveMeningeal Nerve
It travels with the middleIt travels with the middle
meningeal artery to providemeningeal artery to provide
sensory innervation to thesensory innervation to the
duramater.duramater.

Branches in theBranches in the
PterygopalatinePterygopalatine
fossafossa::
After exiting the cranium throughAfter exiting the cranium through
the foramen Rotundum, thethe foramen Rotundum, the
maxillary division crosses themaxillary division crosses the
pterygopalatine fossa. Here itpterygopalatine fossa. Here it
gives several branches:gives several branches:
 The zygomatic nerveThe zygomatic nerve
 The pterygopalatineThe pterygopalatine
(sphenopalatine) nerve(sphenopalatine) nerve
 The posterior superiorThe posterior superior
alveolar nervealveolar nerve

The Pterygopalatine NerveThe Pterygopalatine Nerve
These are two short trunksThese are two short trunks
that unite in thethat unite in the
pterygopalatine ganglionpterygopalatine ganglion
and are then redistributedand are then redistributed
into several branches.into several branches.
Branches of this nerveBranches of this nerve
include those that supplyinclude those that supply
- The orbit- The orbit
- The nose- The nose
- The palate and- The palate and
- The pharynx- The pharynx

The zygomatic nerve-The zygomatic nerve-
This nerve comes off theThis nerve comes off the
maxillary division in themaxillary division in the
pterygopalatine fossa andpterygopalatine fossa and
travels anteriorly ,enteringtravels anteriorly ,entering
the orbit through the inferiorthe orbit through the inferior
orbital fissure, where itorbital fissure, where it
divides into:divides into:
-- Zygomaticotemporal andZygomaticotemporal and
- Zygomaticofacial- Zygomaticofacial nervesnerves

Nasal BranchesNasal Branches
Supply -Supply -
-- Mucus membrane of the superior and middle conchaeMucus membrane of the superior and middle conchae
- The lining of the posterior ethmoidal sinuses- The lining of the posterior ethmoidal sinuses
- Posterior portion of the nasal septum- Posterior portion of the nasal septum

Palatine BranchesPalatine Branches
- Greater Palatine nervesGreater Palatine nerves
[anterior][anterior]
(Supply palatal soft(Supply palatal soft
tissuestissues
and bone as far as theand bone as far as the
first premolar)first premolar)
- Lesser palatine nervesLesser palatine nerves
[middle&posterior][middle&posterior]
(Mucous membrane of the(Mucous membrane of the
soft palate)soft palate)

The Posterior Superior Alveolar NerveThe Posterior Superior Alveolar Nerve
The nerve descends from the mainThe nerve descends from the main
trunk of the maxillary division in thetrunk of the maxillary division in the
pterygopalatine fossapterygopalatine fossa and runsand runs
anterioinferiorly to pierce theanterioinferiorly to pierce the
infratemporal surface of maxilla;infratemporal surface of maxilla;
descending under the mucosa ofdescending under the mucosa of
maxillary sinus supplies sinus andmaxillary sinus supplies sinus and
form a part of superior dentalform a part of superior dental
plexus, supplies upper gum andplexus, supplies upper gum and
part of adjoining cheekpart of adjoining cheek

BranchesBranches Infra orbitalInfra orbital
CanalCanal --
The Maxillary division gives off twoThe Maxillary division gives off two
branches significance in dentistry-branches significance in dentistry-
- The middle superior alveolar and- The middle superior alveolar and
- The anterior superior alveolar- The anterior superior alveolar
nerve.nerve.

The Middle superior alveolar nerve : (MSA)The Middle superior alveolar nerve : (MSA)
The site of origin of the MSA nerve varies, fromThe site of origin of the MSA nerve varies, from
the posterior portion of the infra orbital canalthe posterior portion of the infra orbital canal
to the anterior portion ,to the anterior portion ,
near the infra orbital foramen. It arises fromnear the infra orbital foramen. It arises from
infraorbital nerve,infraorbital nerve,
Runs in the infraorbital groove forwardsRuns in the infraorbital groove forwards
in the lateral wall of maxillary sinus.in the lateral wall of maxillary sinus.
The MSA nerve provides sensory innervation to theThe MSA nerve provides sensory innervation to the
- max. premolars- max. premolars
- mesiobuccal root of the first molar and- mesiobuccal root of the first molar and
- periodontal tissues, buccal soft tissue and bone in the premolar- periodontal tissues, buccal soft tissue and bone in the premolar
region.region.

The Anterior superior alveolar nerve : (ASA)The Anterior superior alveolar nerve : (ASA)
Descending within the anterior wall of the maxillary sinus,Descending within the anterior wall of the maxillary sinus,
It provides pulpal innervations to –It provides pulpal innervations to –
• The central , lateral incisors and the canine andThe central , lateral incisors and the canine and
Sensory innervations to -Sensory innervations to -
• The periodontal tissues, buccal bone and mucousThe periodontal tissues, buccal bone and mucous
membrane of these teeth .membrane of these teeth .

The ASA nerve communicates withThe ASA nerve communicates with
MSA nerve and gives off a smallMSA nerve and gives off a small
nasal branch that innervates thenasal branch that innervates the
anterior part of nasal cavityanterior part of nasal cavity
along with pterygopalatinealong with pterygopalatine
nerves.nerves.
DENTAL PLEXUSDENTAL PLEXUS – Nerve– Nerve
networks or actual innervationnetworks or actual innervation
of all individual roots, bone -inof all individual roots, bone -in
both maxilla and mandible isboth maxilla and mandible is
supplied by terminal branchessupplied by terminal branches
Three types of nerves emergeThree types of nerves emerge
from these.from these.
--Dental nervesDental nerves
-Interdental branches and-Interdental branches and
-Interradicular branches-Interradicular branches

Branches on theBranches on the FaceFace ::
Infra orbital nerve emergesInfra orbital nerve emerges
through the infra orbitalthrough the infra orbital
foramen onto the face toforamen onto the face to
divide into its terminaldivide into its terminal
branches-branches-
--The inferior palpebral branchesThe inferior palpebral branches
-The external nasal branches-The external nasal branches
-Superior labial branches.-Superior labial branches.

Mandibular NerveMandibular Nerve
It is the largest trigeminal division.It is the largest trigeminal division.
It has a large sensory root whichIt has a large sensory root which
arises from the inferior anglearises from the inferior angle
of trigeminal ganglion.of trigeminal ganglion.
Motor root arise from cells locatedMotor root arise from cells located
in pons and medullain pons and medulla
oblongata.oblongata.
The 2 roots emerge from craniumThe 2 roots emerge from cranium
throughthrough Foramen OvaleForamen Ovale, motor, motor
root lying medial to sensory.root lying medial to sensory.
They unite outside the skull andThey unite outside the skull and
form the Main Trunk.form the Main Trunk.
This remains undivided for 2- 3This remains undivided for 2- 3
mm and then spilt intomm and then spilt into
Small AnteriorSmall Anterior
Large Posterior DivisionsLarge Posterior Divisions

Branches:Branches:
Branches from theBranches from the
undivided nerveundivided nerve
--Nervous spinosisNervous spinosis
-Nerve to Internal-Nerve to Internal
Pterygoid MusclePterygoid Muscle
Branches from the dividedBranches from the divided
nervenerve
-Anterior division-Anterior division
-Posterior division-Posterior division

The Meningeal branch( nervus spinosus)The Meningeal branch( nervus spinosus)
It enters cranium through foramen spinosum with middleIt enters cranium through foramen spinosum with middle
meningeal arterymeningeal artery
Divides into Anterior and Posterior branches.Divides into Anterior and Posterior branches.
Supply – duramater of middle cranial fossaSupply – duramater of middle cranial fossa
lesser extent in anterior fossa, calvariumlesser extent in anterior fossa, calvarium
Posterior supply the mucous lining of mastoid air cellsPosterior supply the mucous lining of mastoid air cells
The nerve to Medial pterygoidThe nerve to Medial pterygoid
enters the deep aspect of its muscle, then pass throughenters the deep aspect of its muscle, then pass through
Otic ganglionOtic ganglion
- Tensor tympaniTensor tympani
- Tensor veli palatiniTensor veli palatini

Anterior DivisionAnterior Division
Smaller than posterior division, It passes under the LateralSmaller than posterior division, It passes under the Lateral
pterygoid muscle and then on its external surface bypterygoid muscle and then on its external surface by
passing between the 2 heads of the muscle from here it ispassing between the 2 heads of the muscle from here it is
calledcalled Buccal nerve./ Buccinator nerve.Buccal nerve./ Buccinator nerve.
At the level of occlusal plane of mandibular 3At the level of occlusal plane of mandibular 3rdrd
molar it crosses the anterior border of ramus and entersmolar it crosses the anterior border of ramus and enters
the cheek through buccinator musclethe cheek through buccinator muscle
Sensory supply toSensory supply to skin of cheek, buccal gingiva of mandibular molarsskin of cheek, buccal gingiva of mandibular molars
and mucobuccal foldand mucobuccal fold
((anaesthesia of buccal nerve is needed for procedures requiring softanaesthesia of buccal nerve is needed for procedures requiring soft
tissue manipulation of buccal surfaces of mandibular molarstissue manipulation of buccal surfaces of mandibular molars))

Branches of AnteriorBranches of Anterior
divisiondivision
-Branch to external pterygoid-Branch to external pterygoid
musclemuscle
- Branch to masseter muscle- Branch to masseter muscle
- Branches to temporal- Branches to temporal
musclesmuscles
* Anterior deep temporal* Anterior deep temporal
nervenerve
* Posterior deep temporal* Posterior deep temporal
nervenerve
- Buccal nerve [Long Buccal]- Buccal nerve [Long Buccal]
The buccal nerve does notThe buccal nerve does not
innervate the buccinatorinnervate the buccinator
muscle nor the lower lip. itmuscle nor the lower lip. it
supplied bysupplied by Facial nerveFacial nerve

Branch to External PterygoidBranch to External Pterygoid
musclemuscle
It enters the medial side of theIt enters the medial side of the
external pterygoid muscle toexternal pterygoid muscle to
provide motor nerve supply.provide motor nerve supply.
Branch to Masseter muscleBranch to Masseter muscle
Passes above the externalPasses above the external
pterygoid to traverse thepterygoid to traverse the
mandibular notch and enter themandibular notch and enter the
deep side of the masseterdeep side of the masseter
muscle.muscle.

Posterior trunkPosterior trunk
It is sensory but receivesIt is sensory but receives
a few filaments from thea few filaments from the
motor root.motor root.
It divides intoIt divides into
• AuriculotemporalAuriculotemporal
• Lingual nerveLingual nerve
• Inferior alveolar nerveInferior alveolar nerve

Auriculotemporal nerveAuriculotemporal nerve
-has 2 roots that embrace the middle-has 2 roots that embrace the middle
meningeal artery and unite behind themeningeal artery and unite behind the
arteryartery
-The united nerve passes posteriorly-The united nerve passes posteriorly
deep to the external pterygoid muscledeep to the external pterygoid muscle
and neck of the condyleand neck of the condyle
-It traverses the upper deep part of the parotid gland-It traverses the upper deep part of the parotid gland
or its fascia and then crosses the posterior root of the zygomatic archor its fascia and then crosses the posterior root of the zygomatic arch
BranchesBranches ::
Parotid BranchesParotid Branches
Articular BranchesArticular Branches
Auricular BranchesAuricular Branches
Meatal BranchesMeatal Branches
Terminal BranchesTerminal Branches

Lingual nerveLingual nerve
OriginOrigin:: From posterior trunk of mandibular nerve in the infratemporal fossa.From posterior trunk of mandibular nerve in the infratemporal fossa.
CourseCourse:: First it passes medially to the external pterygoid muscle and as it descendsFirst it passes medially to the external pterygoid muscle and as it descends
lies between internal pterygoid muscle & ramus of the mandible in thelies between internal pterygoid muscle & ramus of the mandible in the
pterygomandibular spacepterygomandibular space
- Here it passes parallel to the IAN but medial and anterior to it, then passes deepHere it passes parallel to the IAN but medial and anterior to it, then passes deep
to reach the base of the tongueto reach the base of the tongue
- At the side of the tongue it lies below the lateral lingual sulcusAt the side of the tongue it lies below the lateral lingual sulcus
Branches supplyBranches supply
• Mucous membrane of the floor of the mouthMucous membrane of the floor of the mouth
• Lingual surface of the gumLingual surface of the gum
• Mucous membrane of anterior 2/3Mucous membrane of anterior 2/3rdrd
of tongue expect vallate papillaof tongue expect vallate papilla
It carries postganglionic fibres from submandibular ganglion for sublingual salivary and anteriorIt carries postganglionic fibres from submandibular ganglion for sublingual salivary and anterior
lingual glandlingual gland

Inferior alveolar nerveInferior alveolar nerve
Descends medial to the lateral pterygoid and then at itsDescends medial to the lateral pterygoid and then at its
lower border passes between the sphenomandibularlower border passes between the sphenomandibular
ligament and mandibular ramus to enter through theligament and mandibular ramus to enter through the
mandibular foramen into mandibular canal, it runs belowmandibular foramen into mandibular canal, it runs below
the teeth to the mental foramen to divide intothe teeth to the mental foramen to divide into
incisiveincisive andand mentalmental branches.branches.
Below the lateral pterygoidBelow the lateral pterygoid it is accompanied by inferiorit is accompanied by inferior
alveolar artery. Inferior dental nerve in most mandibles isalveolar artery. Inferior dental nerve in most mandibles is
plexiform and does not occupy a single canal. It is joinedplexiform and does not occupy a single canal. It is joined
through plexiform branches, such accessory dentalthrough plexiform branches, such accessory dental
nerves ramify in a plane lateral to molar teeth; thisnerves ramify in a plane lateral to molar teeth; this
accounts for incomplete anaesthesia by inferior dentalaccounts for incomplete anaesthesia by inferior dental
nerve block.nerve block.

Branches of inferior alveolar nerveBranches of inferior alveolar nerve
• The Mylohoid nerve-The Mylohoid nerveit is a mixed nerve being motor toit is a mixed nerve being motor to
its muscle and anterior belly of digastric,its muscle and anterior belly of digastric,
• It is sensory to mandibular incisorsIt is sensory to mandibular incisors
• Branches to molar and premolar teethBranches to molar and premolar teeth
• Incisive nerve-Incisive nerve- in innervates pulpal tissues ofin innervates pulpal tissues of
mandibular 1mandibular 1stst
premolar, canine, incisorspremolar, canine, incisors
• Mental nerve-Mental nerve- exists through mental foramen and supplyexists through mental foramen and supply
skin of chin, skin and mucous membrane of lower lipskin of chin, skin and mucous membrane of lower lip

SubmandibularSubmandibular ganglionganglion
• IT IS A SMALL OVOID BODY SUSPENDED FROM TWO LINGUAL NERVEIT IS A SMALL OVOID BODY SUSPENDED FROM TWO LINGUAL NERVE
ABOVE THE SUBMANDIBULAR SALIVARY GLAND.IT IS A PARASYMPATHETICABOVE THE SUBMANDIBULAR SALIVARY GLAND.IT IS A PARASYMPATHETIC
GANGLION.GANGLION.
• THOUGH RELATED TO LINGUAL NERVES IT IS CONNECTED FUNCTIONALYTHOUGH RELATED TO LINGUAL NERVES IT IS CONNECTED FUNCTIONALY
WITH THE FACIAL AND CHORDATYMPANI NERVE.WITH THE FACIAL AND CHORDATYMPANI NERVE.
• THE POSTGANGLIONIC PARASYMPATHETIC FIBERS SUPPLY SECRETORYTHE POSTGANGLIONIC PARASYMPATHETIC FIBERS SUPPLY SECRETORY
FIBERS TO THE SUBMANDIBULAR AND SUBLINGUAL SALIVARY GLAND.FIBERS TO THE SUBMANDIBULAR AND SUBLINGUAL SALIVARY GLAND.
Otic ganglionOtic ganglion
• THE GANGLION IS LOCATED ON THE MEDIAL SIDE OF THE UNDITHE GANGLION IS LOCATED ON THE MEDIAL SIDE OF THE UNDI
VIDED BRANCH OF MANDIBULAR DIVISION.VIDED BRANCH OF MANDIBULAR DIVISION.
• PARASYMPATHETIC PREGANGLIONIC SECRETORY FIBERS.PARASYMPATHETIC PREGANGLIONIC SECRETORY FIBERS.
• THESE FIBERS ARISE IN THE INFERIOR SALIVATORY NUCLEUS.THESE FIBERS ARISE IN THE INFERIOR SALIVATORY NUCLEUS.
THIS GROUP OF CELLS ARISE IN THE FLOOR OF THE FOURTHTHIS GROUP OF CELLS ARISE IN THE FLOOR OF THE FOURTH
VENTRICLE IN MEDULLA.VENTRICLE IN MEDULLA.

PATHWAY OF PAIN FROM MANDIBULAR FIRST MOLAR.PATHWAY OF PAIN FROM MANDIBULAR FIRST MOLAR.
 WHEN A PERIPHERAL NOCICEPTOR IS STIMULATED A SERIES OFWHEN A PERIPHERAL NOCICEPTOR IS STIMULATED A SERIES OF
EVENTS OCCUR THAT CARRY, IMPULSE INTO THE CNS AND TOEVENTS OCCUR THAT CARRY, IMPULSE INTO THE CNS AND TO
THE HIGHER CENTER FOR INTERPRETATION AND EVALUATION.THE HIGHER CENTER FOR INTERPRETATION AND EVALUATION.
 THE IMPULSE IS CARRIED BY PRIMARY AFFERENT NEURON OFTHE IMPULSE IS CARRIED BY PRIMARY AFFERENT NEURON OF
MANDIBULAR DIVISION OF TRIGEMINAL NERVE THROUGHMANDIBULAR DIVISION OF TRIGEMINAL NERVE THROUGH
GASSERION GANGLIA INTO SUB NUCLEUS CAUDALIS .GASSERION GANGLIA INTO SUB NUCLEUS CAUDALIS .
IT SYNAPSES WITH SECOND ORDER NEURON TO BEIT SYNAPSES WITH SECOND ORDER NEURON TO BE
TRANSFERRED TO HIGHER CENTRES.TRANSFERRED TO HIGHER CENTRES.
 IF THE INPUT IS CARRIED BY A DELTA FIBRE IT MAY SYNAPSEIF THE INPUT IS CARRIED BY A DELTA FIBRE IT MAY SYNAPSE
WITH WIDE RANGE OF NEURON AND CARRIED BY THE WAY OFWITH WIDE RANGE OF NEURON AND CARRIED BY THE WAY OF
NST TRACT AND THIS IS REFERRED TO AS FAST PAIN.NST TRACT AND THIS IS REFERRED TO AS FAST PAIN.
 IF THE INPUT IS CARRIED BY C FIBRE IT MAY SYNAPSE WITHIF THE INPUT IS CARRIED BY C FIBRE IT MAY SYNAPSE WITH
NOCICEPTIVE SPECIFIC NEURON AND CARRIED UPTO PALEONOCICEPTIVE SPECIFIC NEURON AND CARRIED UPTO PALEO
SPINOTHALAMIC TRACT. THIS IS INTERPRETED AS SLOW PAIN.SPINOTHALAMIC TRACT. THIS IS INTERPRETED AS SLOW PAIN.

Applied anatomyApplied anatomy

Evaluation of the trigeminal NerveEvaluation of the trigeminal Nerve
SENSORY ROOT:SENSORY ROOT:
TRIGEMINAL NERVE CARRIES SENSORY FIBERSTRIGEMINAL NERVE CARRIES SENSORY FIBERS
FROM CORNEA. THE CORNEAL REFLEXES CAN BEFROM CORNEA. THE CORNEAL REFLEXES CAN BE
TESTED BY OBSERVING PATIENTS BLINK INTESTED BY OBSERVING PATIENTS BLINK IN
RESPONSE TO LIGHT TOUCH ON THE CORNEARESPONSE TO LIGHT TOUCH ON THE CORNEA
WITH A STERILE COTTON PLEDGETWITH A STERILE COTTON PLEDGET..
MOTOR ROOT.MOTOR ROOT.
THE PATIENT IS ASKED TO CLENCH HIS TEETH.THE PATIENT IS ASKED TO CLENCH HIS TEETH.
THE TEMPORALIS AND MASSETER MUSCLETHE TEMPORALIS AND MASSETER MUSCLE
SHOULD STAND OUT WITH EQUAL PROMINENCESHOULD STAND OUT WITH EQUAL PROMINENCE
ON EACH SIDE. IF THERE IS PARALYSIS ON ONEON EACH SIDE. IF THERE IS PARALYSIS ON ONE
SIDE THE MUSCLE ON THAT SIDE WILL FAIL TOSIDE THE MUSCLE ON THAT SIDE WILL FAIL TO
BECOME PROMINENT.BECOME PROMINENT.

Nerve injuriesNerve injuries
 MAXILLOFACIAL TRAUMAMAXILLOFACIAL TRAUMA..
INFRAORBITAL NERVE.INFRAORBITAL NERVE.
ZYGOMATICO ORBITAL NERVEZYGOMATICO ORBITAL NERVE..
 MANDIBULAR ANGLE AND BODYMANDIBULAR ANGLE AND BODY
FRACTURES.FRACTURES.
INFERIOR ALVEOLAR NERVE.INFERIOR ALVEOLAR NERVE.
LINGUAL NERVELINGUAL NERVE
 MAXILLARY AND MID FACIAL FRACTURES.MAXILLARY AND MID FACIAL FRACTURES.
PALATINE NERVES ARE AFFECTEDPALATINE NERVES ARE AFFECTED..

INJURIES TO NERVES DURING SURGICAL PROCEDURESINJURIES TO NERVES DURING SURGICAL PROCEDURES
ORTHOGNATHIC SURGERY.ORTHOGNATHIC SURGERY.
 SAGITAL OSTEOTOMIES.SAGITAL OSTEOTOMIES.
 BILATERAL SPLITOSTEOTOMIES.BILATERAL SPLITOSTEOTOMIES.
THESE SURGERIES RESULT IN INJURY TO INFERIOR ALVEOLAR NERVETHESE SURGERIES RESULT IN INJURY TO INFERIOR ALVEOLAR NERVE..
GENIOPLASTYGENIOPLASTY..
 MENTAL NERVE IS INJURED.MENTAL NERVE IS INJURED.
THIRD MOLAR EXTRACTION.THIRD MOLAR EXTRACTION.
 INFERIOR ALVEOLAR AND LINGUAL NERVE ARE INJURED.INFERIOR ALVEOLAR AND LINGUAL NERVE ARE INJURED.
IMPLANT PLACEMENT.IMPLANT PLACEMENT.
 INFERIOR ALVEOLAR AND LINGUAL NERVE ARE MOST COMMONLYINFERIOR ALVEOLAR AND LINGUAL NERVE ARE MOST COMMONLY
AFFECTED.AFFECTED.
DURING RESECTION PROCEDURES.DURING RESECTION PROCEDURES.
DURING SALIVARY GLAND REMOVAL AND RADICAL LYMPHADENECTOMYDURING SALIVARY GLAND REMOVAL AND RADICAL LYMPHADENECTOMY
 LINGUAL NERVE IS AFFECTEDLINGUAL NERVE IS AFFECTED

Clinical considerationsClinical considerations
Complete division of one trigeminal nerve will result in aComplete division of one trigeminal nerve will result in a
unilateral sensory loss over one side of the face andunilateral sensory loss over one side of the face and
scalp in the area of Vth nerve distribution and paralysisscalp in the area of Vth nerve distribution and paralysis
of the muscles of masticationof the muscles of mastication
Peripheral nerve damage may be caused by fracturesPeripheral nerve damage may be caused by fractures
,increasing pressure in the cavernous sinus area by,increasing pressure in the cavernous sinus area by
aneurysm and by tumorsaneurysm and by tumors

Anesthesia DolorosaAnesthesia Dolorosa
Is one of the most dreaded complications of neurosurgeryIs one of the most dreaded complications of neurosurgery
and is considered to be non-reversible. It occurs whenand is considered to be non-reversible. It occurs when
the trigeminal nerve is damaged by surgery or physicalthe trigeminal nerve is damaged by surgery or physical
trauma in such a way that the feeling sensation in parttrauma in such a way that the feeling sensation in part
of the face is reduced or eliminated entirely while theof the face is reduced or eliminated entirely while the
sense of pain remains.sense of pain remains.

CausesCauses
anesthesia dolorosa is caused by injury to the trigeminal nerve oranesthesia dolorosa is caused by injury to the trigeminal nerve or
as a complication of surgery to correct a condition such asas a complication of surgery to correct a condition such as
trigeminal neuralgia . It can occur aftertrigeminal neuralgia . It can occur after
 glycerol injectionglycerol injection
 alcohol injectionalcohol injection
 partial nerve sectionspartial nerve sections
 radiofrequency rhizotomyradiofrequency rhizotomy
 gamma knife surgerygamma knife surgery
 balloon compressions andballoon compressions and
 microvascular decompression.microvascular decompression.

SymptomsSymptoms
The two main symptoms of AD are facial numbnessThe two main symptoms of AD are facial numbness
(much like the numbness from a dental anesthetic(much like the numbness from a dental anesthetic
injection) and constant pain.injection) and constant pain.
The pain is usually burning, pulling or stabbing but canThe pain is usually burning, pulling or stabbing but can
also include a sharp, stinging, shooting or electricalalso include a sharp, stinging, shooting or electrical
component.component.
Pressure and "heaviness" can also be part of the painPressure and "heaviness" can also be part of the pain
symptoms. Often there is eye pain.symptoms. Often there is eye pain.
Cold increases the feeling of numbness sometimesCold increases the feeling of numbness sometimes
making the face feel frozen.making the face feel frozen.www.indiandentalacademy.comwww.indiandentalacademy.com

DiagnosisDiagnosis
In the past, diagnosis of anesthesia dolorosa was based onIn the past, diagnosis of anesthesia dolorosa was based on
symptoms. More recently, thermograms ( a test that measuressymptoms. More recently, thermograms ( a test that measures
minute temperature differences in the painful area) and nerveminute temperature differences in the painful area) and nerve
blocks of the sympathetic nervous system are sometimes usedblocks of the sympathetic nervous system are sometimes used
in diagnosis.in diagnosis.
TreatmentsTreatments
No single treatment has been found yet that resolvesNo single treatment has been found yet that resolves
all of the pain. However there are a number ofall of the pain. However there are a number of
treatment options that can help to manage the paintreatment options that can help to manage the pain
and discomfortand discomfort

Forms of Trigeminal neuralgiaForms of Trigeminal neuralgia
Seven formsSeven forms
 Typical Trigeminal neuralgiaTypical Trigeminal neuralgia
 Atypical Trigeminal neuralgiaAtypical Trigeminal neuralgia
 Pre-Trigeminal neuralgiaPre-Trigeminal neuralgia
 Multiple-Sclerosis related Trigeminal neuralgiaMultiple-Sclerosis related Trigeminal neuralgia
 Secondary or Tumor related Trigeminal neuralgiaSecondary or Tumor related Trigeminal neuralgia
 Trigeminal neuropathyTrigeminal neuropathy
 ““Failed” Trigeminal neuralgiaFailed” Trigeminal neuralgia

Trigeminal NeuralgiaTrigeminal Neuralgia
The best known form of facial neuralgia is theThe best known form of facial neuralgia is the
Trigeminal neuralgia orTrigeminal neuralgia or Tic douloureuxTic douloureux
DEFINITIONDEFINITION ::
T N is defined as sudden , usually unilateral ,T N is defined as sudden , usually unilateral ,
severe , brief stabbing , lancinating , recurringsevere , brief stabbing , lancinating , recurring
pain in the distribution of one or more branchespain in the distribution of one or more branches
of 5th cranial nerve.of 5th cranial nerve.

JOHN LOCKEJOHN LOCKE in 1677 gave the first fullin 1677 gave the first full
description with its treatment.description with its treatment.
NICHOLAS ANDRENICHOLAS ANDRE in 1756 coined the termin 1756 coined the term
“tic doloureux”“tic doloureux”
JOHN FOTHERGILLJOHN FOTHERGILL in 1773 publishedin 1773 published
detailed description of tn , since then , itdetailed description of tn , since then , it
has been referred to as “fothergill’shas been referred to as “fothergill’s
disease”.disease”.

Clinical featuresClinical features
 Extreme pain that is stabbing, burning or shockingExtreme pain that is stabbing, burning or shocking
lasting from several seconds to minutes.lasting from several seconds to minutes.
 Able to be provoked by tactile or thermal stimulationAble to be provoked by tactile or thermal stimulation
over a Trigger zone.over a Trigger zone.
 Anatomically confined to the division of one or moreAnatomically confined to the division of one or more
divisions of the nerve unilaterally.divisions of the nerve unilaterally.
 It does not have any objective motor or sensoryIt does not have any objective motor or sensory
nerve deficits in the affected area.nerve deficits in the affected area.

Management of trigeminal neuralgiaManagement of trigeminal neuralgia
This is the first line of approach for most of the TNThis is the first line of approach for most of the TN
patients .patients .
TN does not respond to analgesics includingTN does not respond to analgesics including
opiates .opiates .
Blom [ 1962 ] showed response to anticonvulsantBlom [ 1962 ] showed response to anticonvulsant ..
Carbamazepine [Tegretol]Carbamazepine [Tegretol]
DOSE ; 100 mg 3 times
a day.
SIDE EFFECTS ; visual blurring , drowsiness ,
mental confusion , dizziness , ataxia .& in
rare cases hepatic dysfunction , leucopenia

PHENYTOINPHENYTOIN
DOSE be administered I.V
to treat exacerbations
of TN ; 100mg 3 times
a day
.
SIDE EFFECTS ; slurred
speech , ataxia
[ decreased coordination
] , gingival hypertrophy.

BACLOPHENBACLOPHEN
[ LIORESAL][ LIORESAL]
DOSE ; 10 mg 3 times a day .
SIDE EFFECTS ; drowsiness ,
dizziness ,nausea & leg weakness
GABAPENTIN [NEURONTIN ]
DOSE ; starting dose 300mg TID
SIDE EFFECTS ; sleepiness ,
ataxia , fatigue

Surgical managementSurgical management

INTERRUPTION OF PAIN PATHWAYSINTERRUPTION OF PAIN PATHWAYS
BETWEEN CENTRE AND PERIPHERYBETWEEN CENTRE AND PERIPHERY
EXTRACRANIALLY INTRACRANIALLY
- Alcohol block in Peripheral
nerve .
- Nerve section & avulsion
-Cryosurgery.
-Radiofrequency
thermacoagulation.
.
Gasserion Ganglion Procedures
1. Percutaneous rhizotomies .
percutaneous glycerol inj .
percutaneous balloon compression
rhizotomies.
radiofrequency rhizotomies.
2 . Microvascular decompression.

Atypical Trigeminal NeuralgiaAtypical Trigeminal Neuralgia
It is characterized by unilateral prominent constantIt is characterized by unilateral prominent constant
and severe aching ,boring or burning painand severe aching ,boring or burning pain
superimposed upon otherwise typical TN symptoms.superimposed upon otherwise typical TN symptoms.
Pain can be relieved with medications used forPain can be relieved with medications used for
typical TN .typical TN .
Its important to note that Rhizotomy procedures mayIts important to note that Rhizotomy procedures may
be effective in treating atypical TN.be effective in treating atypical TN.

Pre- Trigeminal NeuralgiaPre- Trigeminal Neuralgia
Days to years before the first attack of TN pain ,someDays to years before the first attack of TN pain ,some
sufferers experience odd sensation of pain ,this maysufferers experience odd sensation of pain ,this may
be pre-trigeminal neuralgia.be pre-trigeminal neuralgia.
It is most effectively treated with medical therapyIt is most effectively treated with medical therapy
used for typical TN.used for typical TN.

Multiple-Sclerosis Related Trigeminal NeuralgiaMultiple-Sclerosis Related Trigeminal Neuralgia
Symptoms are similar to typical TNSymptoms are similar to typical TN
Bilateral TN is more commonly seen in people withBilateral TN is more commonly seen in people with
multiple sclerosis.multiple sclerosis.
Treated with same medications used for typical TNTreated with same medications used for typical TN
Trigeminal Rhizotomies are employed whenTrigeminal Rhizotomies are employed when
medications fail to control the painmedications fail to control the pain

Secondary or Tumor-Related TNSecondary or Tumor-Related TN
TN pain caused by a lesion ,such as a tumor is referredTN pain caused by a lesion ,such as a tumor is referred
to as secondary TNto as secondary TN
A tumor that severely compresses or distorts theA tumor that severely compresses or distorts the
Trigeminal nerve may cause facial numbness, weaknessTrigeminal nerve may cause facial numbness, weakness
of chewing muscles or constant aching pain.of chewing muscles or constant aching pain.
Medications help to control TN , surgically removing ofMedications help to control TN , surgically removing of
tumor usually subsides pain and returns trigeminaltumor usually subsides pain and returns trigeminal
function.function.

Trigeminal Neuropathy orTrigeminal Neuropathy or
Post-Traumatic Trigeminal NeuralgiaPost-Traumatic Trigeminal Neuralgia
This neuralgia may develop following cranio -facialThis neuralgia may develop following cranio -facial
trauma such as, dental trauma , sinus trauma .trauma such as, dental trauma , sinus trauma .
Pain is constant, aching , burning but may bePain is constant, aching , burning but may be
worsened by exposure to Triggers such as wind andworsened by exposure to Triggers such as wind and
cold.cold.
Treatment of this neuralgia is often ineffective andTreatment of this neuralgia is often ineffective and
pain may not be controlled with medications. Painpain may not be controlled with medications. Pain
relief may be there by trigeminal nerve stimulationrelief may be there by trigeminal nerve stimulation
procedures.procedures. www.indiandentalacademy.comwww.indiandentalacademy.com

““Failed” Trigeminal NeuralgiaFailed” Trigeminal Neuralgia
In few sufferers all medications ,micro vascularIn few sufferers all medications ,micro vascular
decompressions and destructive rhizotomydecompressions and destructive rhizotomy
procedures prove in effective in controlling pain ,procedures prove in effective in controlling pain ,
this condition is called “Failed” TNthis condition is called “Failed” TN
Investigational treatments may be consideredInvestigational treatments may be considered
including stimulation of the brain surface orincluding stimulation of the brain surface or
stimulation of the trigeminal nerve or Gasserianstimulation of the trigeminal nerve or Gasserian
Ganglion.Ganglion. www.indiandentalacademy.comwww.indiandentalacademy.com

Para-Trigeminal SyndromePara-Trigeminal Syndrome
Raeder’s SyndromeRaeder’s Syndrome
It is characterized by severe headache or pain in theIt is characterized by severe headache or pain in the
area of the trigeminal distributionarea of the trigeminal distribution
Seen most commonly in middle aged malesSeen most commonly in middle aged males
The cause is unknownThe cause is unknown

 SYRINGOBULBIA.SYRINGOBULBIA.
 WALLENBERG’S OR SUPERIOR ORBITAL FISSUREWALLENBERG’S OR SUPERIOR ORBITAL FISSURE
SYNDROME.SYNDROME.
 DIABETIC NEUROPATHY.DIABETIC NEUROPATHY.
 TRIGEMINO CARDIAC REFLEX.TRIGEMINO CARDIAC REFLEX.
 GRADENIGO SYNDROME.GRADENIGO SYNDROME.
 POST HERPETIC NEURALGIA.POST HERPETIC NEURALGIA.

SYRINGO BULBIA.SYRINGO BULBIA.
DAMAGE TO SENSORY NUCLEI OF TRIGEMINAL NERVEDAMAGE TO SENSORY NUCLEI OF TRIGEMINAL NERVE
RESULTS IN SEGMENTAL SENSORY LOSS.COMMONLY SEEN INRESULTS IN SEGMENTAL SENSORY LOSS.COMMONLY SEEN IN
SYPHILIS.SYPHILIS.
WALLENBERG’S OR SUPERIOR ORBITAL FISSURE SYNDROME.WALLENBERG’S OR SUPERIOR ORBITAL FISSURE SYNDROME.
LOSS OF PAIN AND TEMPERATURE SENSATION ON EPSILATERALLOSS OF PAIN AND TEMPERATURE SENSATION ON EPSILATERAL
HALF OF THE FACE DUE TO DAMAGE TO OPHTHALMICHALF OF THE FACE DUE TO DAMAGE TO OPHTHALMIC
NERVE IN FRACTURES RESULTING IN CRANIOFACIALNERVE IN FRACTURES RESULTING IN CRANIOFACIAL
DISJUNCTIONDISJUNCTION
DIABETIC NEUROPATHY.DIABETIC NEUROPATHY.
THE POLYNEUROPATHIC CHANGES RESULTS IN PRICKINGTHE POLYNEUROPATHIC CHANGES RESULTS IN PRICKING
DYSESTHESIA OF UPPER EYELID, ACHING PAINS ABOVE THEDYSESTHESIA OF UPPER EYELID, ACHING PAINS ABOVE THE
EYE AND OCCASSIONAL FRONTAL HEADACHE.THIS IS DUEEYE AND OCCASSIONAL FRONTAL HEADACHE.THIS IS DUE
TO ACTIVATION OF PAIN SENSITIVE NERVE ENDINGS IN THETO ACTIVATION OF PAIN SENSITIVE NERVE ENDINGS IN THE
BRANCHES OF TRIGEMINAL NERVE.BRANCHES OF TRIGEMINAL NERVE.

TRIGEMINO CARDIAC REFLEX.TRIGEMINO CARDIAC REFLEX.
IT IS THE SUDDEN ONSET OF DYSRHYTHMIA ANDIT IS THE SUDDEN ONSET OF DYSRHYTHMIA AND
HYPOTENSION DURING MANIPULATION OF ANY ONE OF THEHYPOTENSION DURING MANIPULATION OF ANY ONE OF THE
BRANCHES OF TRIGEMINAL NERVE. COMMONLY SEENBRANCHES OF TRIGEMINAL NERVE. COMMONLY SEEN
DURING CRANIOFACIAL SURGERY AND TUMOR RESECTION INDURING CRANIOFACIAL SURGERY AND TUMOR RESECTION IN
CEREBELLOPONTINE ANGLE.CEREBELLOPONTINE ANGLE. GRADENIGO SYNDROME.GRADENIGO SYNDROME.
CHARECTERISED BYSUPPURATIVE OTITIS, TRIGEMINAL NERVECHARECTERISED BYSUPPURATIVE OTITIS, TRIGEMINAL NERVE
PAIN AND ABDUCENS NERVE PALSY.PAIN AND ABDUCENS NERVE PALSY.
POST HERPETIC NEURALGIA.POST HERPETIC NEURALGIA.
THIS IS DUE TO INFECTION OF NERVOUS SYSTEM BYTHIS IS DUE TO INFECTION OF NERVOUS SYSTEM BY
VARICELLA ZOSTER VIRUS. COMMONLY SEEN IN ELDERLY,VARICELLA ZOSTER VIRUS. COMMONLY SEEN IN ELDERLY,
WITH SEVERE RASH AND WITH INVOLVEMENT OFWITH SEVERE RASH AND WITH INVOLVEMENT OF
OPHTHALMIC NERVE.OPHTHALMIC NERVE.

Infectious Diseases affecting Trigeminal NerveInfectious Diseases affecting Trigeminal Nerve
 Herpes ZosterHerpes Zoster
 Leprous NeuropathyLeprous Neuropathy
 Diphtheritic NeuropathyDiphtheritic Neuropathy
 Neuro syphilisNeuro syphilis

Clinical considerations during AnesthesiaClinical considerations during Anesthesia
 Soft tissue injurySoft tissue injury
 HematomaHematoma
 Pain on injectionPain on injection
 EdemaEdema
 Sloughing of tissuesSloughing of tissues
 InfectionInfection
 TrismusTrismus
 Needle breakageNeedle breakage

Soft tissue injurySoft tissue injury
CauseCause: in younger children and: in younger children and
mentally/ physically disabledmentally/ physically disabled
children or adults. It is becausechildren or adults. It is because
the soft tissue anesthesia laststhe soft tissue anesthesia lasts
longer than the pulpal anesthesia.longer than the pulpal anesthesia.
The patient bites or chews theseThe patient bites or chews these
areas while still anesthetized.areas while still anesthetized.
PreventionPrevention::
 A local anesthetic of appropriate durationA local anesthetic of appropriate duration
should be given.should be given.
 the patient and guardian warned againstthe patient and guardian warned against
eating, drinking hot fluids, or biting oneating, drinking hot fluids, or biting on
lips.lips.
 A cotton roll can be placed between lipsA cotton roll can be placed between lips
and teeth secured with dental floss toand teeth secured with dental floss to
prevent aspirationprevent aspiration..

ManagementManagement::
 AnalgesicsAnalgesics
 Antibiotics if infectionAntibiotics if infection
developsdevelops
 Lukewarm saline rinsesLukewarm saline rinses
 Petroleum jelly to lubricatePetroleum jelly to lubricate
and reduce irritationand reduce irritation

HematomaHematoma
The effusion of blood into extra vascular spaces can result fromThe effusion of blood into extra vascular spaces can result from
inadvertently nicking a blood vessel (artery / vein).inadvertently nicking a blood vessel (artery / vein).
CauseCause: Density of tissue in the hard palate and its firm adherence to bone: Density of tissue in the hard palate and its firm adherence to bone
it rarely develops after a palatal injection.it rarely develops after a palatal injection.
It usually result from either arterial or venous puncture afterIt usually result from either arterial or venous puncture after PosteriorPosterior
superior alveolar injection or Inferior alveolar block.superior alveolar injection or Inferior alveolar block.
Hematomas of Inferior alveolar are visible intraorally, whereas PSAHematomas of Inferior alveolar are visible intraorally, whereas PSA
hematomas are seen extraorallyhematomas are seen extraorally
PreventionPrevention::
 Knowledge of the normal anatomy.Knowledge of the normal anatomy.
 Modify the injection techniqueModify the injection technique
 Use of short needleUse of short needle
 Minimize the number of needle penetrationsMinimize the number of needle penetrations

ManagementManagement
When swelling evident after injection, direct pressure should beWhen swelling evident after injection, direct pressure should be
applied at the site of bleeding. In most of the injections theapplied at the site of bleeding. In most of the injections the
vessel lies between the skin and bone on which pressure isvessel lies between the skin and bone on which pressure is
applied not less than 2 minutes.applied not less than 2 minutes.
In Inferior alveolar block:In Inferior alveolar block: Pressure is applied to the medialPressure is applied to the medial
aspect of mandibular ramus.aspect of mandibular ramus.
Anterior superior alveolar block:Anterior superior alveolar block: Pressure is applied on the skinPressure is applied on the skin
directly over infraorbital foramen.directly over infraorbital foramen.
Mental (Incisive) block:Mental (Incisive) block: pressure applied directly over mentalpressure applied directly over mental
foramenforamen

Posterior superior alveolar block:Posterior superior alveolar block:
 here bleeding occurs into infratemporal fossa. It appears ashere bleeding occurs into infratemporal fossa. It appears as
colorless swelling on the side of the face, which progresses towardscolorless swelling on the side of the face, which progresses towards
lower anterior region of chin.lower anterior region of chin.
 Location of the bleeding site is difficult as it is posterior, superior,Location of the bleeding site is difficult as it is posterior, superior,
and medial to maxillary tuberosity.and medial to maxillary tuberosity.
 Digital pressure can be applied in the superior and medial directionDigital pressure can be applied in the superior and medial direction
the mucobuccal fold distally as possible without producing gagthe mucobuccal fold distally as possible without producing gag
 Ice can be placed extraorally to constrict the vesselIce can be placed extraorally to constrict the vessel
 Analgesics likeAnalgesics like aspirinaspirin can be prescribedcan be prescribed
 Heat should not be applied as it produces vasodilatationHeat should not be applied as it produces vasodilatation

TrismusTrismus
Derived from Greek word trismos, is a prolonged tetanic spasmDerived from Greek word trismos, is a prolonged tetanic spasm
of the jaw muscles by which the normal opening of the mouthof the jaw muscles by which the normal opening of the mouth
is restricted.is restricted.
CauseCause::
 Trauma to muscles or blood vessels in the infratemporal fossaTrauma to muscles or blood vessels in the infratemporal fossa
during dental injections.during dental injections.
 Local anesthetics have slight mycotoxic properties on skeletalLocal anesthetics have slight mycotoxic properties on skeletal
musclesmuscles
 HemorrhageHemorrhage
 Low grade infectionLow grade infection

Prevention and managementPrevention and management
 Use of sharp, sterile, disposable needle.Use of sharp, sterile, disposable needle.
 Aseptic techniqueAseptic technique
 Avoid repeated injections and multiple insertionsAvoid repeated injections and multiple insertions
 Heat therapy- hot moist towels to the affected area for 20Heat therapy- hot moist towels to the affected area for 20
min every hourmin every hour
 Warm saline rinseWarm saline rinse
 Patient is advised for physiotherapy, and lateralPatient is advised for physiotherapy, and lateral
excursions of mandible 5 min every 3 – 4 hours.excursions of mandible 5 min every 3 – 4 hours.
 Other therapies include Ultrasound, surgical interventionOther therapies include Ultrasound, surgical intervention
to correct chronic dysfunctionto correct chronic dysfunction

Pain on injectionPain on injection
Cause:Cause:
• Careless injection techniqueCareless injection technique
• Rapid deposition of local anestheticRapid deposition of local anesthetic
• Needle with barbsNeedle with barbs
PreventionPrevention
 Use of sterile anesthetic solutionsUse of sterile anesthetic solutions
 Inject the solution slowlyInject the solution slowly
 Be certain that the temperature of the solution isBe certain that the temperature of the solution is
correct( too hot/ cold solution is uncomfortable tocorrect( too hot/ cold solution is uncomfortable to
the patient)the patient)

EdemaEdema::
It is clinical sign of the presence of disorderIt is clinical sign of the presence of disorder
CausesCauses::
• Trauma during injectionTrauma during injection
• InfectionInfection
• Allergy( Angioedema is common response to ester type topicalAllergy( Angioedema is common response to ester type topical
anesthetics allergic patients- vasodilation occurs secondary toanesthetics allergic patients- vasodilation occurs secondary to
histamine release )histamine release )
• HemorrhageHemorrhage
• Injection of irritating solutions( containing alcohol or cold sterilizingInjection of irritating solutions( containing alcohol or cold sterilizing
solutions)solutions)
PreventionPrevention
• Complete medical historyComplete medical history
• Use sterile solutionsUse sterile solutions
• Atraumatic techniqueAtraumatic technique

 Edema which is due to irritating solutions will resolve without formal treatmentEdema which is due to irritating solutions will resolve without formal treatment
 If signs of infection like pain, mandibular dysfunction, warmth are present then antibioticIf signs of infection like pain, mandibular dysfunction, warmth are present then antibiotic
therapy is giventherapy is given
 Allergic edema( location is important ) administration of Intramuscular/ oral histamine blockerAllergic edema( location is important ) administration of Intramuscular/ oral histamine blocker
If edema occurs in area that compromises breathingIf edema occurs in area that compromises breathing
 P(position): supineP(position): supine
 A-B-C: (airway, breathing, circulation)- basic life support neededA-B-C: (airway, breathing, circulation)- basic life support needed
 D(definitive treatment)D(definitive treatment)
 Epinephrine is given IM/IV every 10 to 15 min until respiratory distress resolvesEpinephrine is given IM/IV every 10 to 15 min until respiratory distress resolves
 Histamine blockerHistamine blocker
 Corticosteroid therapyCorticosteroid therapy
 In total airway obstruction preparation made for CRICOTHYROTOMYIn total airway obstruction preparation made for CRICOTHYROTOMY

Needle BreakageNeedle Breakage
CausesCauses
 Weakening of the needle by bending it before insertionWeakening of the needle by bending it before insertion
 Sudden unexpected movement by patientSudden unexpected movement by patient
 Smaller needles(30 gauge) are more likely to break compared to 25 gauge.Smaller needles(30 gauge) are more likely to break compared to 25 gauge.
 Manufacture defect in the needleManufacture defect in the needle
ManagementManagement::
 Remain calmRemain calm
 Instruct the patient not to moveInstruct the patient not to move
 Keep the patients mouth openKeep the patients mouth open
If the fragment is visible try to remove it with a small hemostat or Magill intubationIf the fragment is visible try to remove it with a small hemostat or Magill intubation
forcepsforceps
 If the needle is not visibleIf the needle is not visible
 -do not proceed with incision-do not proceed with incision
 -calmly inform the patient-calmly inform the patient
 -note the incident on patients chart-note the incident on patients chart
 -refer the patient to Oral and maxillofacial surgeon-refer the patient to Oral and maxillofacial surgeon

Sloughing of tissuesSloughing of tissues
Prolonged irritation and ischemia of gingival soft tissues may lead toProlonged irritation and ischemia of gingival soft tissues may lead to
unpleasant complicationsunpleasant complications
Epithelial desquamationEpithelial desquamation
CausesCauses
 Application of topical anesthetic agent to gingival tissues for a prolongedApplication of topical anesthetic agent to gingival tissues for a prolonged
periodperiod
 Increased sensitivity of tissues to anestheticsIncreased sensitivity of tissues to anesthetics
Sterile abscessSterile abscess
 Secondary to prolonged ischemia with use of LA containing vasoconstrictorSecondary to prolonged ischemia with use of LA containing vasoconstrictor
 Usually develops on hard palateUsually develops on hard palate
Is symptomatic, analgesics for painIs symptomatic, analgesics for pain
Epithelial desquamation resolves in few daysEpithelial desquamation resolves in few days
Sterile abscess may run 7 to 10 daysSterile abscess may run 7 to 10 days

ConclusionConclusion

BibliographyBibliography
 Textbook of Oral and maxillofacial surgeryTextbook of Oral and maxillofacial surgery
- Neelima Anil malik- Neelima Anil malik
 Burket’s oral medicine, diagnosis and treatment, 9Burket’s oral medicine, diagnosis and treatment, 9thth
editionedition
 Gray’s anatomy, the anatomical basis of medicine and surgery,Gray’s anatomy, the anatomical basis of medicine and surgery,
3838thth
editionedition
 Moheim’s local anesthesia and pain control in dental practice, 7Moheim’s local anesthesia and pain control in dental practice, 7thth
editionedition
 Contemporary oral and maxillofacial surgery -Peterson, 3Contemporary oral and maxillofacial surgery -Peterson, 3rdrd
editionedition
 Handbook of Local anesthesia, 5Handbook of Local anesthesia, 5thth
edition - Stanley F. Malamededition - Stanley F. Malamed

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