BDS [Orthodontics] course

1. TRIGEMINAL NEURALGIA
PROF (Dr.) SAIBEL FARISHTA

2. Trigeminal Neuralgia (TN), also known as Tic
Douloureux, is considered by many to be the "most terrible
pain known to man." The electric shock-like pain generally
is on one side of the face and is spasmodic, coming in short
bursts lasting a few seconds. Several attacks can follow
each other within minutes. There are often trigger points,
places on the face which, if touched, trigger an attack..
Eating, shaving, applying makeup and talking can be
triggers. There can be periods of remission when pain is
completely absent. These periods of remission, which can
last days, weeks, months, even years, are unpredictable
and without medical treatment, the pain usually returns

3. ANATOMY
The trigeminal nerve is one
of 12 pairs of cranial nerves
that originate at the base of
the brain. The nerve has
three branches that conduct
sensations from the upper,
middle, and lower portions
of the face, as well as the
oral cavity, to the brain

4. BRANCHES
The trigeminal nerve is the
fifth of twelve pairs of
cranial nerves enervating the
face and head, and is
denoted by the Roman
Numeral V. It has three
divisions which enervate the
forehead and eye (ophthalmic
V1), cheek (maxillary V2)
and lower face and jaw
(mandibular V3).

5. The 3 divisions of the
trigeminal come together in
an area called the Gasserion
ganglion.the trigeminal nerve
root continues back towards
the side of the brain
stem,inserts into the pons.
Within the brainstem signals
traveling through the
trigeminal reach specialized
clusters of neurons called the
trigeminal nerve nucleus

6. NERVE BRANCHES
Trigeminal nerve
opthalmic maxillary MANDIBULAR
Ant.ethmoid
post.ethmoid
lacrimal
infratrochlear
Supraorbital
supratrochlera
nasocilliary
zygomaticotemporal
zygomaticofacial
Post.sup.alveolar
nasopalatine
greaterpalatine
lesserpalatine
Mid n ant alveoler
infraorbital
auriculotemporal
lingual
Inf.alveoler
n. To myloyoid
mental
buccal

7. Typical Trigeminal Neuralgia (Tic
Douloureux)
This is the most common form of
TN, that has previously been termed
Classical, Idiopathic and Essential
TN. Nearly all cases of typical TN are
caused by blood vessels compressing
the trigeminal nerve root as it enters
the brain stem. This neurovascular or
microvascular compression at the
trigeminal nerve root entry zone may
be caused by arteries of veins, large
or small, that may simply contact or
indent the trigeminal nerve. In people
without TN, blood vessels are usually
not in contact with the trigeminal nerve
root entry zone.
AA

8.  Pulsation of vessels upon the
trigeminal nerve root do not
visibly damage the nerve.
However, irritation from repeated
pulsations may lead to changes
of nerve function,and delivery of
abnormal signals to thetrigeminal
nerve nucleus.Over time, this is
thought to cause hyperactivity of
the trigeminal nerve
nucleus,resulting in the
generation of TN pain.
The sup. cerebellar artery is the vessel
most often responsible for
neurovascular compression upon the
Vnerve root,although other arteries
or veins may be the culprit vessels.

9. B. Atypical Trigeminal Neuralgia
Atypical TN characterized by unilateral, prominent
constant and severe aching, boring or burning pain
superimposed upon otherwise typical TN
symptoms.This should be differentiated from cases
of typical TN that develop a minor aching or burning
pain within the affected distribution of the trigeminal
nerve.
Vascular compression, as described above in
typical TN, is thought to be the cause of many
cases of atypical TN. Some believe atypical TN is
due to vascular compression upon a specific part of
the trigeminal nerve,while others theorize that
atypical TN represents a more severe form or
progression of typical TN

10. C. Multiple Sclerosis-Related Trigeminal
Neuralgia
 The symptoms and characteristics
of multiple sclerosis (MS)-related
TN are identical to those for
typical TN. Those with MS-related
TN tend to be younger when they
experience their first attack of
pain, and the pain progresses
over a shorter amount of time
than in those with typical TN.
Furthermore, bilateral TN is more
commonly seen in people with
multiple sclerosis.
MS involves the formation of demyelinating plaques
within the brain. When these areas of injury involve the
trigeminal nerve system, TN may develop.

11. Demyelinization of the nerve. In rare instances (less
than 3%), TN is a symptom of Multiple Sclerosis which
destroys the myelin sheaths protecting nerve fibers.
Trigeminal Neuralgia is rarely the first symptom of
Multiple Sclerosis and typically appears in advanced
stages of MS.

12. D.Secondary or Tumor Related Trigeminal
Neuralgia
 Trigeminal neuralgia pain caused by
a lesion, such as a tumor, is referred
to as secondary trigeminal
neuralgia. A tumor that severely
compresses or distorts the
trigeminal nerve may cause facial
numbness, weakness of chewing
muscles, and/or constant aching
pain (also see Trigeminal
Neuropathy or Post-Traumatic
Trigeminal Neuralgia).

13. Trigeminal Neuropathy or Post-
Traumatic TN
 Trigeminal Neuropathy or
Post-Traumatic TN may
develop following
Cranio-facial trauma
Dental procedure like extraction
Sinus trauma
DENTAL EXTRATION

14. symptom
 Dysesthesia – An
unpleasant abnormal
sensation, whether
spontaneous or evoked
Allodynia – Pain due to a
stimulus which does not
normally provoke pain, such as
pain caused by light touch to the
skin

15. PT
Hyperalgesia – An increased
response to a stimulus which is
normally painful
Hyperesthesia - Increased sensitivity
to stimulation, excluding the special
senses. Hyperesthesia includes both
allodynia and hyperalgesia, but the
more specific terms should be used
wherever they are applicable.

16. Area of Pain

The area of facial pain is
reflected by which of the three
branches of the trigeminal
nerve is affected. From the
brief "anatomy “ above, we see
that
 V1 (Opthalmic) the first branch
affects the eye, forehead and
nose.
 V2 (Maxillary) the second
branch affects upper teeth,
gum and lip, the cheek, lower
eyelid and the side of the nose.
 V3 ((Mandibular) the third
branch affects lower teeth,
gum, lower lip and jaw.
v1
v2
v3

17. TN diagnosed
 Diagnosis is generally based on the patient’s medical history and
description of symptoms, a physical exam, and a thorough
neurological examination by a physician.
correct diagnosis is difficult Because of overlapping
symptoms, and the large number
of conditions that can cause
facial pain, such as post-herpetic neuralgia,
can cause similar facial pain, as
do syndromes such as cluster
headaches
,MRI for tumours,MRangiography for compression

18. TREATMENT

19. Surgery
 Microvascular
Decompression Surgery

20. Percutaneous
Rhizotomies

21. Percutaneous Balloon
Compression Rhizotomy

22. Radiofrequency
Rhizotomy

23. Stereotactic Radiosurgery
(Gamma Knife

24. Not all cases of TN may be effectively controlled with
any one form of medications or surgical interventions.
When medications are no longer effective, surgical
interventions are considered

25. THANK YOU