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TRIGEMINAL NERVE Contents: 1. Introduction 2. Sensory & motor roots 3. Trigeminal ganglion 4. Divisions 5. Ophthalmic nerve Origin Course Branches and innervation 6. Maxillary nerve Origin Course Branches and innervation Anesthesia 7. Mandibular nerve Origin Course Branches and innervation Anesthesia 8. The needle Parts Length Gauge 9. Trigeminal nerve evaluation 10. Applied anatomy 11. Trigeminal neuralgia Etiology Pathophysiology Clinical features Diagnosis Management Differential diagnosis

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12. Other common conditions affecting trigeminal nerve Trigeminal peripheral neuritis Post-traumatic trigeminal neuralgia Auriculotemporal syndrome 13. Conclusion 14. References INTRODUCTION The knowledge of trigeminal nerve is needed by the dental practitioner for several reasons most important being pain management that involves administration of local anesthesia during dental treatment. As this nerve also supplies various muscles of mastication and temporomandibular joint, it is responsible for coordinated movements during mastication and speech. Also there are certain nervous system disorders of head and neck that requires thorough knowledge of trigeminal nerve for its diagnosis and management. Trigeminal nerve is a fifth cranial nerve. It is a mixed cranial nerve that means it has both afferent and efferent fibers. Afferent fiber means sensory nerve that carries information from periphery of the body to the brain and efferent fiber means motor nerve that carries information away from brain to the periphery of the body. Trigeminal nerve is the largest cranial nerve. It arises as a short, thick sensory trunk and a smaller motor component from the ventrolateral aspect of the pons. The nerve passes anteriorly over the petrous temporal ridge and into a tunnel of dura known as trigeminal or meckels cave within the middle cranial fossa. Within the cave, the nerve flattens out as the large trigeminal ganglion and this in turn give rise to three divisions namely ophthalmic, maxillary and mandibular nerve. TRIGEMINAL GANGLION Also known as semilunar or gasserian ganglion. It is crescentic or semilunar in shape. It is made up of pseudounipolar nerve cells with T shaped

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arrangement. It lies on trigeminal impression on anterior surface of petrous temporal bone near its apex and occupies space of dura mater called meckels cave. Central process of ganglion cells form large sensory root while peripheral processes forms three divisions of trigeminal nerve. From the convexity of the ganglion emerges three divisions and concavity receives sensory root of the nerve. MOTOR ROOT It arises separately from the sensory root, originating in the motor root within the pons and medulla oblongata. Its fibers, forming small nerve root travels anteriorly along with but entirely separate from larger sensory root to the region of semilunar ganglion. Passes in a lateral and inferior direction under the ganglion towards the foramen ovale, through which it leaves the middle cranial fosssa along with the third division of sensory root. Just after leaving skull, motor root unites with sensory root of mandibular division to form a main trunk. Motor fibers supply the following muscles: 1. Masticatory muscles Masseter, temporalis, medial pterygoid and lateral pterygoid. 2. Mylohyoid 3. Anterior belly of diagastric 4. Tensor tympani 5. Tensor veli palatine. SENSORY ROOT Sensory root fibers of the trigeminal nerve comprise the central process of ganglion cell located in the trigeminal ganglion which is attached to the brain. They are distributed through three divisions of the nerve. It supplies: 1. Skin of the face and anterior half of the head. 2. Mucus membrane of the nose, air sinuses, mouth, and anterior two-third of the tongue. 3. Teeth and temporomandibular joint.

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4. Contents of the orbit except the retina. 5. Part of dura mater Some afferent fibers carry propriceptive impulses from the muscles of mastication. DIVISIONS OF THE NERVE 1. Ophthalmic division (V1) This exit the skull through superior orbital fissure into the orbit. 2. Maxillary division(V2) Exits the cranium through the foramen rotundum into the upper portion of the pterygopalatine fossa. 3. Mandibular division(V3) Exits the skull, along with motor root, through foramen ovale and enters the infratemporal fossa. OPHTHALMIC NERVE Origin- The ophthalmic division is the first branch of the trigeminal nerve. It arises from anteriomedial part of the ganglion. This branch is exclusively sensory and smallest of the three divisions. Course- it pierces the dura of the trigeminal cave and comes to lie in the lateral wall of the cavernous sinus below the trochlear nerve. Passing forward it division into three branches, these branches enter the orbit by passing through superior orbital fissure. It supplies the eyeball, conjunctiva, lacrimal gland, parts of the mucus membrane of the nose and paranasal sinuses and the skin of the forehead, eyelids and nose. Branches and innervation- three main branches are- nasociliary, frontal and lacrimal nerve. Frontal nerveIt is the largest branch of the ophthalmic division, runs forward between levator palpebrae superioris and roof of the orbit.

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It ends by dividing into supraorbital and supratrochlear branches. Supraorbital nerve- it continues in the of line of the frontal nerve, reaching the orbital margin it passes through the supraorbital notch and curves upwards into the forehead. It divides into medial and lateral branches that supply the scalp as far as the lambdoid suture. Other branches areBranches to the conjunctiva and skin of the upper eyelid, branches to the mucus membrane of the frontal sinus, some branches to the deeper tissue of the scalp. Clinical implication- in frontal sinusitis pain is referred to the area of the scalp supplied by the supraorbital nerve ( frontal headache). Supratrochlear nerve- runs forward and medial to the supraorbital nerve, reaching the upper margin of the orbital aperture nerve turns upwards into forehead giving branches to the skin over its lower and medial part. Other branches are- a descending branch which joins the infratrochlear branch of the nasociliary nerve, branches to the conjunctiva and skin of the upper eyelid. Lacrimal nerve- it is the smallest branch of the ophthalmic nerve, runs along the lateral wall of the orbit and ends in the lacrimal gland hence its name. It supplies the conjunctiva and the skin of the upper eyelid. The nerve also delivers the postganglionic parasympathetic nerve to the lacrimal gland. These nerves are responsible for the production of lacrimal fluid or tears. Nasociliary nerve- on entering the orbit this nerve lies between the optic nerve and lateral rectus. The nerve then runs medially crossing above the optic nerve, reaching the medial wall of the orbit, it divides into the anterior ethmoidal and infratrochlear nerves. Branches of the nasociliary nerve are as follows: Sensory root of the ciliary ganglion- it carries sensory fibers that begin in the cornea, iris and the choroid, passes to the ciliary ganglion Long ciliary nerves- generally two or more. It pierces the sclera and then runs between the sclera and the choroid. They supply sensory fibers to the ciliary body, iris

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and the cornia. They also carry postganglionic sympathetic fibers meant for the dilator papillae. Posterior ethmoidal branch- enters the posterior ethmoidal foramen present on the medial wall of the orbit and supplies the ethmoidal and sphenoidal air sinuses. Anterior ethmoidal nerve- it courses through the orbit and anterior cranial fossa, leaves the fossa by passing into a slit at the side of crista galli and leads into the nasal cavity. It gives: a) internal nasal branch which supplies the nasal septum and lateral wall of nasal cavity, b) external nasal nerve which suppies skin over the lower part of the nose. Infratrochlear nerve- runs forward on medial wall of the orbit and end by supplying part of the skin of the upper and lower eyelids and over the upper part of the nose. Also gives branches to the conjunctiva, lacrimal sac and lacrimal caruncle. MAXILLARY NERVE Origin- this is the second branch of the trigeminal nerve, arises from the middle of the trigeminal ganglion. Intermediate in size between ophthalmic and the mandibular division. Course- piercing the dura, it comes to lie in the lower part of the lateral wall of the cavernous sinus, the nerve leaves the middle cranial fossa through the foramen rotundum to reach the uppermost part of the pterygopalatine fossa. It passes into the orbit through the inferior orbital fissure and lies in infraorbital canal. It appears on the face through the infraorbital foramen and ends by dividing into a number of terminal branches. Branches and innervations Various branches are 1) Within the cranium- middle meningeal nerve 2) In the pterygopalatine fossa- zygomatic nerve, pterygopalatine nerve and posterior superior alveolar nerve. 3) In the infraorbital canal- middle superior alveolar nerve, anterior superior alveolar nerve

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4) On the face- inferior palpebral branches, external nasal branch, superior labial branches. Middle meningeal nerve- immediately after separating from the trigeminal ganglion, the maxillary division gives off a small branch, the middle meningeal nerve which provides sensory innervation to the dura mater. Zygomatic nerve- it comes off the in the pterygopalatine fossa and travels anteriorly entering the orbit through the inferior orbital fissure where it divides into- A) zygomaticotemporal- supplying sensory innervation to the skin on the side of the forehead. B) zygomaticofacial- supplying the skin on the prominence of the cheek. Pterygopalatine nerves- these are two short trunks that unite in the pterygopalatine ganglion and are then redistributed into several branches. Its branches supply four areas- orbit, nose, palate and pharynx. A) orbital branchthis enters the orbit through the inferior orbital fissure and supplies the periosteum of the orbit. B) nasal branches- supplies the mucus membranes of the superior and middle conchae, the lining of the posterior ethmoidal sinuses, and the posterior portion of the nasal septum. One of its branch nasopalatine nerve continue downward and reaches floor of nasal cavity and gives branches to the anterior part of nasal septum and the floor of the nose. It enters incisive canal and passes into the oral cavity via incisive foramen located in midline of palate about 1 cm posterior to maxillary central incisors, right and left nasopalatine nerves emerge together through this foramen and provides sensation to the palatal mucosa in the region of the premaxilla. C) palatine branches are greater palatine nerve- it emerges on the hard palate through greater palatine foramen which is usually located about 1 cm towards the palatal midline just distal to second molar. The nerve courses anteriorly between the mucoperiosteum and the osseus hard palate, supplying sensory innervation to the palatal hard and soft tissues as far as first premolar, where it communicates with terminal fibers of the nasopalatine nerve. Middle palatine nerve emerges from lesser palatine foramen and provides sensory innervation to the mucus membrane of the soft palate. Posterior palatine nerve also emerges from lesser palatine foramen and innervates tonsillar region. D) pharyngeal branch- its a small nerve, passes through the pharyngeal canal

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and is distributed to the mucus membrane of the nasal part of the pharynx, posterior to the auditory tube. Posterior superior alveolar nerve (PSA )- its the last branch to arise from the maxillary nerve within the pterygopalatine fossa. Commonly there are two PSA branches and occasionally one . when two trunks are present, one remains external to the bone and continues downward on the posterior surface of the maxilla and supplies the buccal gingival in the maxillary molar region and adjacent facial mucosa(gingival branch). The other branch enters into the maxilla through the posterior alveolar foramina and enters the sinus and descends down the posterolateral wall towards the roots of the maxillary molar teeth. As they approaches the teeth forms plexiform-superior alveolar plexus. From the plexus, Dental branches -supplies alveoli, periodontal ligament and pulpal tissue of the maxillary third, second and first molars( with the exception (in 28% patients) of the mesiobuccal root of the first molar). Other branches supply the mucosal lining of the maxillary sinus. Middle superior alveolar nerve(MSA)- while in the infraorbital groove and canal, maxillary division is known as the infraorbital nerve. MSA nerve leaves the infraorbital nerve and passes inferiorly to enter the sinus and forms the intermediate portion of the superior dental plexus which is composed of PSA, MSA and ASA nerves. Middle superior alveolar nerve provides sensory innervation to the pulpal tissue of maxillary premolars and mesiobuccal root of the first molar, periodontal ligament and buccal soft tissue and bone in the premolar region. It has been stated that MSA nerve is absent in 30%-50% of individuals, in its absence innervations are provided by either the PSA or ASA nerve, most frequently the ASA nerve. Anterior superior alveolar nerve(ASA)- this nerve descends within the anterior wall of the maxillary sinus, it forms the anterior portion of the superior dental plexus. This provides sensory innervations to the periodontal tissue, buccal bone and mucus membrane of canines and incisors. It also communicates with MSA nerve and gives off a small nasal branch that innervates the anterior part of the nasal cavity.

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The actual innervations of individual roots of all teeth, bone periodontal structure and both maxilla and mandible derives from terminal branches of larger nerves in the region. These nerve forms network known as dental plexus. Three types of nerve emerges from these plexuses- A) dental- enters a tooth through apical foramen and divides within the pulp. B) interdental (perforating) branch-travels through the entire height of interradicular septum providing innervation to the periodontal ligament of adjacent teeth, emerges at the crest and innervate interdental papillae and buccal gingival. C) inter-radicular branches- traverses inter-radicular septum providing innervations to the periodontal ligament of adjacent roots, terminating in the periodontal ligament at the root furcations. The infraorbital nerve emerges through the infraorbital foramen onto the face to divide into terminal branches. Inferior palpebral branch- ascends to the orbit deep to the orbicularis oculi muscle, supplies the skin of the lower eyelid. External nasal branch- travels toward the lateral aspect of the external nose to supply the skin of the lateral aspect of the nose and mucus membrane of the cartilaginous portion of nasal septum. Superior labial branch- descends deep to the levator labii superioris and supplies the skin and mucus membrane of the upper lip.

Different types of local anesthetic injection technique are1. Local infiltration- small terminal nerve endings in the area of treatment are flooded with local anesthetic solution. 2. Field block- solution is deposited near the larger terminal nerve branches 3. Nerve block- local anesthetic is deposited close to a main nerve trunk usually at a distance from the site of operative intervention. Other supplemental techniques areIntraligamentary injection-LA solution is deposited at the depth of the gingival sulcus along the long axis of the tooth to be treated on its mesial or

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distal of the root. This technique is mainly indicated as an adjunctive after nerve block anesthesia if partial anesthesia is present or in patients for whom residual soft tissue anesthesia is undesirable. Proper needle placement is difficult to achieve in some areas like distal to molars. Intraosseous injection- its the deposition of LA solution into the interproximal bone between two teeth.special syringes are available for this technique , first mark the site which is distal to the tooth to be treated 2 mm apical to gingival margin in a line bisecting interdental papilla. inject LA at the site and then take perforator perpendicular to the cortical plate gently push it through the attached gingiva till it hit the bone, activate the handpiece and perforate the bone, hold the guide sleeve at that point and remove the perforator and insert syringe at the same place and inject LA solution. Intrapulpal injection- this technique is indicated when pain control is necessary for pulpal extirpation or other endodontic treatment in the absence of adequate anesthesia from other techniques, in this wedge the needle firmly into the pulp chamber or root canal and deposit LA solution under pressure. Anesthesia of different branches of maxillary nerve 1. Local infiltration of buccal soft and hard tissues- also known as supraperiosteal injection. Indicated in cases where treatment is limited to one or two teeth. Insert the needle to the height of the muccobuccal fold above the apex of the tooth being anesthetized. 2. Local infiltration of the palate- this is to anesthetize the terminal branches of the greater or nasopalatine nerve. Approach the injection site at 45 angle and insert the needle in the attached gingiva 5-10 mm from the free gingival margin and deposit the LA solution while applying enough pressure. 3. Anterior superior alveolar(ASA) nerve block-in this pulp, buccal periosteum and bone of maxillary central incisor to the canine on the injected side are anesthetize along with lower eyelid, lateral aspect of nose and upper lip. And in about 72% of patients, premolars and mesiobuccal root of the first molar are also anesthetized.

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First locate the infraorbital foramen-feel the infraorbital notch, bone inferior to the notch is convex,as your finger continue downward, a concavity is felt, this is infraorbital foramen. Retract the lip, insert the needle into the height of mucobuccal fold over the first premolar, orient the syringe toward the infraorbital foramen. The needle should be held parallel with the long axis of the tooth as it advances to avoid premature contact with bone. slowly advance the needle until bone is gently contacted. General depth of needle penetration is 16mm, aspirate and slowly deposit 1.2ml of solution. 4. Middle superior alveolar(MSA) nerve block- this is to anesthetize PDL, bone and pulpal tissue of premolars and mesiobuccal root of the first molar. As this nerve is present only in 28% of the population , thereby limiting the clinical usefulness of this technique. Insert the needle into the height of the mucobuccal fold above the second premolar and advance the needle until its tip is located well above the apex of the second premolar and deposit 0.9-1.2ml of LA solution. 5. Posterior superior alveolar(PSA) nerve block- indicated when treatment involves two or more maxillary molars. Goal is to deposit local anesthetic close to the PSA nerve, located posterosuperior and medial to the maxillary tuberosity. Ask the patient to partially open the mouth, retract the cheek and insert the needle into the height of the mucobuccal fold over the second molar. Advance the slowly in an upward, inward and backward direction in one movement. In an adult, penetration depth of 16mm places the needle tip in the immediate vicinity of the foramina through which the PSA nerve enters the posterior surface of maxilla. Slowly deposit 0.9-1.8ml of LA solution. 6. Greater palatine nerve block- this block anesthetizes the posterior portion of the hard palate and its overlying soft tissue, anteriorly as far as the first premolar and medially up to midline. To locate the foramen, place a cotton swab at th junction of maxillary alveolar process and hard palate, start in the region of maxillary first molar and palpate posterior by pressing firmly, the swab falls into the depression created by the foramen. Direct the syringe into the mouth from the opposite

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side with the needle approaching the injection site at a right angle. Insert the needle slightly anterior to the greater palatine foramen and slowly deposit 0.5-0.6ml of solution. 7. Nasopalatine nerve block- this is to anaesthetize the nasopalatine nerve bilaterally i.e the anterior portion of the hard palate from the mesial of the right first premolar to the mesial of the left first premolar. There are 2 techniquesFirst- single needle penetration- target area is incisive foramen, beneath the incisive papilla present between the central incisors. Needle is directed at a 45 angle toward the incisive foramen and solution is deposited in palatal mucosa just lateral to the incisive papilla. Second- multiple needle penetration- this technique is less painful than single needle penetration. First deposit 0.3ml of the LA solution into the labial frenum, second at right angle into the interdental papilla just above the level of crestal bone. Third injection is used only when the second injection does not provide adequate palatal anesthesia. Place the needle into soft tissue adjacent to the incisive papilla aiming towards the distal portion of the papilla and deposit 0.3ml of the solution. 8. Maxillary nerve block- this is to achieve profound anesthesia of hemimaxilla. there are two approaches: First high tuberosity approach- maxillary nerve targeted as it passes through the pterygopalatine fossa. Ask the patient to partially open the mouth, retract the cheek, place the needle into the height of mucobuccal fold over the maxillary second molar. Advance the needle in an upward, inward and backward direction up to a depth of 30mm, no resistance should be felt. At 30mm needle tip should lie in the pterygopalatine fossa in proximity to the maxillary nerve, deposit 1.8 ml of LA solution. Second- greater palatine canal approach- in this technique, the needle passes through the greater palatine canal to reach the pterygopalatine fossa. First locate the greater palatine foramen, apply topical anesthesia

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and direct the syringe into the mouth from opposite side approaching the injection site at right angle, deposit small amount of LA solution and advance the needle into the canal slowly, angle of syringe may be changed to 45 to facilitate the needle insertion. Never penetrate against resistance, depth of penetration is around 30mm, aspirate and deposit 1.8ml of LA solution. MANDIBULAR NERVE Its the largest branch of the trigeminal nerve. Origin- it is a mixed nerve with 2 roots, large sensory root arises from the lateral part of the trigeminal ganglion and the motor root arises in pons and medulla oblongata. Course- the two roots emerge from the cranium separately through the foramen ovale and unites just below the foramen, emerging the foramen ovale the nerve enters the infratemporal fossa. After a short downward course of the main trunk for only 2-3mm, it divides into a smaller anterior division and a large posterior division. Branches: From the undivided trunk- nervus spinosus, medial pterygoid nerve From anterior division- nerve to masseter, nerve to lateral pterygoid, deep temporal nerve, long buccal nerve. From posterior division- auriculotemporal nerve, lingual nerve, inferior alveolar nerve. 1. Nervus spinosus- this branch re-enters cranium through the foramen spinosum along with middle meningeal artery to supply the dura mater and mastoid air cells. 2. Medial pterygoid nerve- this is a motor nerve to medial pterygoid muscle. It gives off small branches that are motor to the tensor veli palatini and tensor tympani.

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3. Nerve to masseter- provides motor innervations to the masseter muscle. 4. Nerve to lateral pterygoid- supplies the lateral pterygoid muscle. 5. Deep temporal nerve- provides innervation to the temporal muscle. 6. Long buccal nerve- this is the only sensory branch from the anterior division.it passes between two heads of lateral pterygoid muscle to reach the external surface of that muscle. At the occlusal plane level of the second of third mandibular molar, it crosses in front of anterior ramus and enters the cheek through the buccinators muscle. It does not innervate buccinator muscle. Sensory fibers distributed to the skin of the cheek. Other fibers pass into retromolar triangle to provide sensory innervation to the buccal gingiva of the mandibular molars and the mucobuccal fold in that region. Anesthesia of this nerve is important for dental procedure requiring soft tissue manipulation on the buccal surface of the mandibular molars. 7. Auriculotemporal nerve- it traverse the upper part of the parotid gland and then gives a number of branches: a communicating branch to facial nerve; a communication with otic ganglion which provides sensory, secretory, and vasomotor fibers to the parotid gland; anterior auricular branch supplying skin over helix and tragus of the ear; branch to external auditory meatus; articular branch to posterior portion of temporomandibular joint; superficial temporal branches to supply skin over the temporal region. 8. Lingual nerve- as it decends downward, it runs between the ramus and the medial pterygoid muscle in the pterygomandibular space. It runs anterior and medial to the inferior alveolar nerve whose path it parallels, reaches the side of the tongue slightly below and behind the mandibular third molar. Hence it lies just below the mucus membrane in lateral lingual sulcus. It proceeds anteriorly across the muscle of the tongue, looping whartons duct and deep to the surface of sublingual gland it breaks into terminal branches: a) it is sensory to the anterior 2/3 of the tongue. Also provides both general and taste sensation for this region. Taste fibers are from chorda tympani which is a branch of

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facial nerve but joins the lingual nerve during its course. b) lingual nerve is also sensory to the mucus membrane of the floor of the mouth and the lingual gingival of the mandible. c) secretomotor fibers for the submandibular and sublingual gland reaches the lingual nerve through the chorda tympani. 9. Inferior alveolar nerve- this is the largest branch of the mandibular division, descends medial to the lateral pterygoid muscle and enters the mandibular canal at the level of the mandibular foramen accompanied by inferior alveolar artery and vein. Mylohyoid nerve- is a branch from inferior alveolar before it enters mandibular canal. Runs forward and downward in the mylohyoid groove on the medial surface of the ramus to reach the mylohyoid muscle. Its a mixed nerve, being motor to the mylohyoid muscle and the anterior belly of diagastric. Sensory to the skin on the inferior and anterior surfaces of the mental protuberance. It may also provide sensory innervation to the mandibular incisors. Inferior alveolar nerve in the mandibular canal forms the inferior dental plexus and serves the mandibular posterior teeth. At the mental foramen, it divides into two terminal branches- incisive and mental nerve. The incisive nerve remains within the canal and forms plexus that innervate the pulpal tissue of the mandibular first premolar, canine and incisors. The mental nerve exits the canal through the mental foramen and divides into three branches that innervate the skin of the chin and skin and mucus membrane of the lower lip. Anesthesia of different branches of mandibular nerve Inferior alveolar nerve block- this technique anesthetizes all the teeth of the quadrants and also anesthetizes buccal mucoperiosteum and mucus membrane anterior to the mandibular first molar and lingual soft tissue innervated by the lingual nerve.

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In this technique, inferior alveolar nerve is targeted as it passes downward towards the mandibular foramen but before it enters into the foramen. Needle is inserted on the medial surface of the mandibular ramus at the intersection of two lines horizontal i.e the height of the injection and vertical representing the anteroposterior plane of injection. Height of injection- an imaginary line extending posteriorly from the finger in the coronoid notch to the deepest part of the pterygomandibular raphe. It should be parallel with mandibular molar occlusal plane. In most cases it lies 6- 10mm above the occlusal plane. Anteroposterior site of injection- point about ! of the distance from the distance the anterior border of the ramus. Ask the patient to open the mouth wide, retract the cheek and insert the syringe from the opposite corner of the mouth at the junction of two lines. Slowly advance the needle it should hit the bone and depth of penetration is around 20-25mm. withdraw the needle by 1mmto prevent subperiosteal injection, aspirate and inject 1.5 ml of the LA solution. Slowly withdraw the needle to its half of the length, reaspirate and inject to anesthetize the lingual nerve. Buccal nerve block- it is a branch of anterior division and supplies the soft tissue and periosteum buccal to the mandibular molar teeth. Injection site is mucus membrane distal and buccal to the most distal molar tooth in the arch. Direct the syringe aligned parallel with the occlusal plane on the side of injection but buccal to the teeth. Penetrate 2-3 mm of mucosa and deposit about 0.3 ml of LA solution. Mental nerve block- this is to provide soft tissue anesthesia buccal to the second premolar. Injection site is nerve as it emerges from the mental foramen. To locate the foramen, place the index finger in the mucobuccal fold in the first molar area and slowly move anteriorly, bone around the foramen is rougher to palpate. Retract the lower lip

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and direct the needle towards the foramen penetrating around 5-6 mm of mucosa and deposit LA solution. Incisive nerve block- this is similar to mental nerve block just we have to penetrate into the mental foramen as incisive nerve remains within the canal supplying the premolars and canine and incisors. Mandibular nerve block- there are two techniques, it anesthetizes inferior alveolar, mental, incisive, lingual, mylohyoid , auriculotemporal and buccal nerves. First technique- gow- gates technique. Target area is lateral side of the condylar neck. Ask the patient to wide open the mouth and direct the syringe from the opposite corner of the mouth. Insert the gently into tissue at the mucus membrane on the mesial of the mandibular ramus just distal to the maxillary molar at the height of its mesiolingual cusp. Align the needle with the plane extending from the corner of the mouth to the intertragic notch on the side of injection. Slowly advance the needle until bone is contacted, depth of penetration is about 25mm, slowly deposit the LA solution. Second technique- vazirani-akinosi closed mouth technique. This is indicated in case of limited mouth opening. Target area is soft tissue on medial border of ramus in the region of nerve as it runs inferiorly from the foramen ovale the towards the mandibular foramen. Height of injection is below the gow-gates site and above the inferior alveolar site. Ask The patient to gently occlude, retract the soft tissue, place the syringe parallel with the maxillary occlusal plane, the needle at the level of the mucogingival junction of the maxillary second and third molars. Direct the needle posteriorly and slightly laterally and advance it parallel with the maxillary occlusal plane. Advance the needle up to 25mm and slowly deposit 1.5ml of the LA solution. Cranial nerve evaluation

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Sensory root is tested by lightly stroking the face with cotton tip bilaterally in 3 regions forehead, cheek and mandible. This will give rough idea of the function of ophthalmic, maxillary and mandibular branches of the nerve. The patient should describe the similar sensation on each side. Gross motor input is tested by having patient clench while feel for both masseter and temporal muscle. The muscles should contract equally on both sides. Applied anatomy 1. Apart from their role in opening and closing the mouth, muscles of mastication are also responsible from side to side movements of the mandible. Contraction of these muscles on one side moves the chin to the opposite side. Normally the chin is maintained in the midline by the balance tone of the muscles of the right and left side. In paralysis of the pterygoid muscle of one side, the chin is pushed to the paralysed side by the muscles of the opposite side. 2. Loss of sensation in the ophthalmic division is of great importance. Normally the eyelids close as soon as the cornea is touched(corneal reflex). Loss of sensation in the cornea abolishes this reflex leaving the cornea unprotected. this can lead to the formation of ulcer on the cornea which can in turn leads to blindness. 3. Pain arising in a structure supplied by one branch of the nerve may be felt in an area of skin supplied by another branch. This is known as referred pain. For example carious tooth(inferior alveolar nerve) may cause pain in the ear(auriculotemporal). And headache is a common symptom when any structure supplied by the trigeminal nerve is involved. 4. Lingual nerve lies in contact with mandible, medial to the third molar tooth. When operating in that region, care must be taken not to injure the lingual nerve.

Trigeminal neuralgia

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Also known as tic doloureux(because of the spasmodic contraction of the facial muscles during the attack) and fothergills disease. Simple definition of neuralgia is pain which follows the path of specific nerves. Trigeminal neuralgia is a facial pain syndrome defined as sudden, usually unilateral, severe, brief, stabbing, lancinating, recurrent pain in the distribution of one or more branches of the fifth cranial nerve. Etiology 1. Primary cause is not known. It is usually idiopathic. 2. Secondary forms can have multiple origin as a) Vascular factors- transient ischemia and autoimmune hypersensitivity may cause the demyelination of the nerve. b) Mechanical factors- pressure of aneurysm of the intrapetrous portion of the internal carotid artery that may erode through the floor of intracranial fossa to exert a pulsatile irritation of the trigeminal ganglion. c) Anatomy of the superior cerebellar artery- the artery lies in contact with the sensory root of the trigeminal nerve and has been implicated as a cause of demyelination. d) Dental etiology- loss of teeth and degeneration of nerve is not restricted to peripheral part of ganglia but proceeds proximally to involve areas of spinal nucleus. e) Infections- involving the 5th cranial nerve can bring about neuralgic pain. f) Jaw bone cavities- alveolar and jaw bone cavities can also be the causative factors. g) Multiple sclerosis- presence of sclerotic plaque located at the root entry zone of the nerve. h) Petrous ridge compression- neuralgia may be caused by compression of the nerve at the dural foramen. i) Post traumatic neuralgia j) Intracranial tumors- such as epidermoid tumors, meningiomas, AV malformations, aneurysms etc. k) Intracranial vascular abnormalities- compression of the intracranial portion of the nerve by a displaced vein or artery.

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l) Viral etiology- history of a previous episode of infection by varicella zoster virus. Clinical characteristics Its a rare disease, seen in about 4 in 100,000 persons. Usually in 5th or 6th decade of life with female predilection and more common on the right side. Mandibular division is most commonly involved and ophthalmic very rare. Trigeminal neuralgia typically manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating, shock like pain, elicited by slight touching superficial trigger points which radiates from one point, across the distribution of one or more branches of the trigeminal nerve. Pain usually confined to one part of one division of trigeminal nerve. Rarely crosses midline. Pain is of short duration and last for few seconds. Paroxysms occur in cycles, each cycle lasting for weeks or months and with time the cycles appears closer and closer. In extreme cases, patient will have a motionless face- the frozen or mask like face Location of trigger points depends on which division is involved. In ophthalmic- over the supraorbital ridge of the affected side. In maxillary nerve- on the skin of upper lip, ala nasi or cheek or the upper gums. In mandibular- over the lower lip, teeth or gums of lower jaw. Characteristic of the disorder, that attacks do not occur during sleep. Patient undergoes indiscriminate dental extractions because pain fiber distribution often mimics pain of odontogenic origin but rarely there is any relief of pain Pathophysiology As proposed by Rappaport and Devor. Pathologic changes occurring in myelin sheath of the fibers of ganglion, dorsal root or both, causes disintegration of myelin sheath that is demyelination of the nerve which causes ectopic firing of a focal group of trigeminal ganglion neurons. This in turn causes cluster of neurons to become hyper excitable and this activity is supplemented by

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activity evoked from a peripheral trigger, causes a aggregation of activity producing a chain reaction and activity spreads to neighboring cells in the ganglion. After a brief period of autonomous firing, activity is quenched and refractory period is initiated by an intrinsic suppressive process engaged as a result of rapid firing. Since the primary abnormality resides in the ganglion and nerve root, normal sensation is present in the periphery between periods of ectopic paroxysmal discharge. Diagnosis Well taken history Pain and triggering occur in the receptor area of the affecting nerve so precisely that analgesic blocking to interrupt the passage of impulses from the superficial peripheral receptors accurately arrests both pain and triggering. This effect is diagnostic. Response to treatment with tablet carbamazepine is universal in trigeminal neuralgia, as in other types of facial pain it is not useful. All the patients should ideally have MRI scanning, it can reveal multiple sclerotic plaques as 1 out of 100 patients with multiple sclerosis suffers from trigeminal neuralgia. Magnetic resorance angiography(MRA) can be useful in locating a vascular compression. Management Treatment considerations should begin with the knowledge of etiology if known. First medical management is advocated. If the patient does not respond to it, then only surgical management is opted. Medical management The most effective drug is carbamazepine (tegretol). It is an anticonvulsant that enhances inactivation of voltage gated sodium channels by reducing high frequency repetitive firing of the action potential. Carbamazepine 100mg thrice daily is introduced and titrated over 1 to 5 weeks period until either remission is achieved

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or side effects are unacceptable. Long term use can cause ataxia, drowsiness, agranulocytosis and aplastic anemia. More recently oxcarbamazepine (trileptal) has been introduced. Its an active metabolite of Carbamazepine that contributes to its advantages while side effects are reduced. Other drugs are Gabapentin (neurontin), Baclofen (lioresal), lamotrigine(lamictal), and tricyclic antidepressants in cases with mild symptoms. Surgical management Peripheral injections- this method is useful when there is welllocalized trigger area. Local anesthetic agent- bupivacaine, injection can be repeated, when pain recurs. Alcohol injection- 95% absolute alcohol. This can cause inflammation and fibrosis. Peripheral neurectomy- this is oldest technique, act by interrupting the flow of a significant number of afferent impulses to central trigeminal apparatus. Disadvantage is of producing anesthetic related dysfunction. There is also the expected eventual return of pain with proliferation of amputed nerve stump neuromas. Cryotherapydirect application of cryotherapy probe at temperature colder than -60c. Rhizotomy- in this selected nerve fibers near or within the gasserian ganglion are either traumatized or destroyed by placing a needle guided by radiographic fluoroscopy into the foramen ovale of the sedated patient. Radiofrequency rhizotomy- selected nerve fibers are destroyed by radiofrequency thermocoagulation. Glycerol rhizotomy- depositing a glycerol. Percutaneous microcompression- traumatizes the nerve fibers by inflating a tiny balloon in the area of the involved nerve fibers. toxic substance such as a

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This procedure appears to be effective without risking neural destruction. Return of symptoms may occur in 1-2 years and complications like loss of facial sensation, masseter muscle weakness and corneal anesthesia which may eventually lead to blindness may occur Microvasular decompression- this procedure involves a craniotomy in which posterior fossa is opened and explored. The offending vessel or lesion that is producing the compression on the nerve is located. The superior cerebellar artery is most common offending artery, it is carefully dissected from the trigeminal nerve and a sponge is placed between the structures. Remarkable relief immediately follows this procedure. Other treatment approaches are Physiologic inhibition of pain by transcutaneous neural stimulation. Acupuncture Psychiatric counseling Hypnosis. Differential diagnosis of trigeminal neuralgia Masticatory pain- since triggering may relate to facial and tongue movements incidental to chewing and swallowing, trigeminal neuralgia must be differential from masticatory pain. Masticatory pain is induced by jaw movements and it may be intense, but true triggering by a light superficial touch and slight movements does not occur. Masticatory pain is not arrested by a conventional mandibular local anesthetic block because the nerve mediating the pain from the joint or masticatory muscles is not anesthetized. Odontalgia Trigeminal neuralgia can cause tooth pain of nondental origin. Following characteristics of true neuralgia contributes to the misdiagnosis.

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Stimulation of a tooth by percussion may trigger neuralgic paroxysm as teeth are part of the sensory receptor system of the affected nerve trunk. Pain is arrested by analgesic blocking of the tooth. Extraction of the tooth may interrupt the neuralgic paroxysm for few days or weeks. Pre-trigeminal neuralgia This condition can also lead to incorrect diagnosis. In this, patient presents with toothache or sinusitis like pain that last up to several hours but pain does not have paroxysmal characteristics. Typical trigeminal neuralgia develops in few days to few years and in some cases patient becomes pain free when taking Carbamazepine or baclofen. These early symptoms are considered the prodrome of trigeminal neuralgia, thus the term pre-trigeminal neuralgia. Glossopharyngeal neuralgia Characteristics are similar to trigeminal neuralgia but location of the initiating stimulus is different. This distinction can be made by immobilizing the mandible and having the patient bite on a bite block which minimizes stimulation of trigeminal structure and by noting whether pain still occurs from the tongue movements and swallowing. Other way is by application of a topical anesthesia to pharyngeal mucosa. This arrests glossopharyngeal neural triggering but does not affects that of trigeminal neuralgia. Other conditions associated with trigeminal nerve Trigeminal peripheral neuritis Peripheral neuritis is a pain condition that relates to the entire peripheral nerve trunk, not just nerve ending and terminal branches.

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Trigeminal peripheral neuritis most frequently involves branches of alveolar nerve. More centrally located inflammatory lesion may induce pain that is more widely located peripherally. With the mandibular division, it may be accompanied by weakness or paralysis of masticatory muscle. Toothache from neuritis would be expressed as discomfort that differs considerably from a typical odontogenious toothache. More importantly neuritis almost invariably causes sensory symptoms such as anesthesia or paresthesia. Herpes zoster it is an acute neuritis of viral source (varicella zoster virus) that presents with pain in the exact distribution of the involved nerve, causes production of tiny vesicles in the peripheral distribution of the nerve. Herpes zoster may involve any of the division but most frequently involve is ophthalmic. The diagnostic clue is the anatomic location of the lesion, which is identical to that of the peripheral superficial distribution of the sensory nerve mediating the pain and its unilateral origin. Herpes zoster pain is not arrested by topical local anesthetic or by regional block. Post-traumatic trigeminal neuralgia It combines the characteristics of both painful neuritis and paroxysmal neuralgia. The disorder has the persistent, unremitting though variable, bright, burning pain that suggest painful neuritis, and may be accompanied by other sensory, motor or autonomic effects. This basic background neuritis pain is interrupted by paroxysms of neuralgic pain. Hence it is also termed as atypical trigeminal neuralgia. History of previous crushing or lacerating injuries of the mouth and face as well as history of surgery helps in the diagnosis. Conclusion

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Overview of the trigeminal nerve and its clinical implications, it would not be wrong to nick name the nerve as the nerve of dental fraternity keeping in mind its significance in this field. Proper knowledge of local anesthetic technique is an indispensible tool in practising painless dentistery which is a corner stone in providing comprehensive and quality dental treatment to our patients. Neuralgias, though rare, are extremely uncomfortable, thus it lies on us, dental surgeons to diagnose the same and help the patient to alleviate, if not rid, the patient of distress and suffering. Reference Anatomy For Dental Student In-derbir Singh 2nd Edition The Anatomical Basis Of Dentistry-Bernard Liebgott 2nd Edition Human Anatomy-Chaurasia 4th Edition Anatomy Of The Head And Neck-Margaret Fehrenbach 3rd Edition Hand Book Of Local Anesthesia-5th Ed Malamed Bells Orofacial Pain-6th Edition Okeson Textbook Of Oral & Maxillofacial Surgery-Neelima Malik Grants Atlas Of Anatomy Human Anatomy-A.K.Datta www.Google.Com

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