TRIGEMINA

L NERVE
DR. VANDANA V. SURAMWAD
MDS FIRST YEAR
DEPT OF CONS & ENDO
 CONTENT

 Introduction
 Nuclear columns of trigeminal nerve
 Branches and Anatomy
 Ganglion
 Clinical anatomy
 Conclusion
 INTRODUCTION

 Fifth and the Largest cranial nerve.

 It is the nerve of first brachial arch.
 It has 3 branches: 1. Ophthalmic – sensory
2. Maxillary – sensory
3. Mandibular – mixed
• The trigeminal nerve originates from three sensory nuclei and one
motor nucleus extending from the midbrain to the medulla.
Nuclear columns are:

1. General somatic afferent column:

• Spinal nucleus of V nerve: It takes pain and temperature sensations
from most of the face area which relay here.

• Superior sensory nucleus: Fibres carrying touch and pressure relay in

this nucleus.

• Mesencephalic nucleus: extends from

pons till midbrain. It receives
proprioceptive impulses from muscles
of mastication, TMJ & teeth.
 Sensory components of V Nerve
 Sensation of pain, temperature, touch and pressure from skin of face,
paranasal air sinuses travel along axons. Their cell bodies lie in the V
ganglion or semilunar ganglion or Gasserian ganglion.
 There are two ganglia one innervating each side of face
 They are located in Meckel’s cave, on anterior surface of petrous
temporal area.
 Sensory root fibers enter the concave portion of each crescent
and the three sensory divisions of trigeminal nerve exit from the
convexity.
 Motar component
 It receives impulses from right and left cerebral hemisperes, red
nucleus and mesencephalic nucleus.
 Fibres of motor root supply four muscles of mastication and four
other muscles that are;
 Tensor veli palatini
 Tensor tympani
 Mylohyoid
 Anterior belly of digastric
 Ophthalmic Nerve (V1)
 FUNCTIONS : The ophthalmic nerve transmits sensory innervation
from;
• Eyeball
• Skin of upper face and anterior scalp
• The lining of upper part of nasal
cavity and air cells
• The meninges of anterior cranial fossa.
• Its branches also convey parasympathetic fibers to the ciliary and iris
muscles for accommodation and pupillary constriction and to the
lacrimal gland.
 Origin, Course and Branches
 It originates from trigeminal ganglion in middle cranial fossa. It
passes anteriorly through lateral wall of cavernous sinus.
 It divides into three branches:
 1. Frontal
2. Nasociliary
3. Lacrimal.
All these branches pass
through superior orbital
fissure into the orbit.
 FRONTAL BRANCH:

 It is the largest branch; supplies frontal sinus and skin of forehead and
scalp.
 It passes through superior orbital fissure outside common tendinous
ring. It passes forwards above levator palpebrae superioris just below
frontal bone.
 It divides into two branches:

Supratrochle
ar
Supraorbi
tal

Frontal
1. Supraorbital: It is the larger and lateral branch.
 It crosses supraorbital margin in the notch or foramen, turns upwards to
supply skin of forehead and scalp as far posterior as the vertex.

2. Supratrochlear: It is the smaller and medial branch

 It supplies upper eyelid
 NASOCILIARY BRANCH:

 It passes the superior orbital fissure, medially within the common

tendinous ring.
 It divides into the following:
a. Short ciliary nerve.
b. Long ciliary nerve.
c. Nerve to ciliary ganglion
d. Infratrochlear
e. Anterior ethmoidal
f. Posterior ethmoidal
 These nerves pass eyeball to innervate ocular structures including
cornea:
 A. Short ciliary nerve contains preganglionic parasympathetic fibers
from Edinger-Westphal nucleus and oculomotor nerve passing to ciliary
ganglion (synapse).
 B. Long and short ciliary nerves also contain sympathetic fibers.

 Anterior ethmoid nerve: It gives sensory fibers to the meninges of

anterior cranial fossa; and enters nasal cavity.
 It supplies along with posterior ethmoidal, upper part of nasal cavity
and sphenoid and ethmoid cells.
 It turns towards bridge of nose and becomes superficial at the junction
of nasal bone and cartilage of nasal bridge.
 Now called as external nasal nerve, supplies cutaneous sensation to
anterior aspect and tip of nose.

 Infratrochlear:
 It supplies both eyelids, side of nose and lacrimal sac.
 LACRIMAL NERVE:

 It supplies lacrimal gland and a small area of adjacent skin and

conjunctiva.
 It passes through superior orbital fissure.
 It receives postganglionic parasympathetic fibers from pterygopalatine
ganglion which enters orbit with zygomatic nerve for distribution to
lacrimal gland.
 Maxillary Nerve (V2)
 It is the nerve of maxillary process, that differentiates from first
pharyngeal arch.
 It is purely sensory; and is intermediate in size between ophthalmic and
mandibular nerve.
 FUNCTIONS:
 The maxillary nerve transmits sensory fibers from the skin of face
between the lower eyelid and the nasal cavity and sinuses, from the
maxillary teeth.
 At its origin from the pons, it contains only sensory fibers.
 some of its branches receive postganglionic parasympathetic fibers
from pterygopalatine ganglion which pass to the lacrimal, nasal and
palatine glands.
 Origin, Course and Branches

 It originates from the middle part of trigeminal ganglion in middle

cranial fossa.
 It gives off meningeal branch in middle cranial fossa which is sensory.
The nerve runs forwards through lower part of lateral wall of cavernous
sinus.
 Then maxillary division is directed through the foramen rotundum into
the uppermost part of pterygopalatine fossa.
 As it crosses pterygopalatine fossa, it gives off its main branches.
 It then angles laterally in a groove on posterior surface of maxilla,
entering the orbit through inferior orbital fissure.
 Within the orbit it occupies the infraorbital groove and becomes
infraorbital nerve which courses anteriorly into the infraorbital canal.
 The maxillary nerve emerges on anterior surface of face through
infraorbital foramen where it divides into its terminal branches,
supplying skin of middle portion of face, nose, lower eyelid and upper
lip.
 Maxillary nerve innervates:

1. Skin of: Middle portion of face

Lower eyelid
Side of nose
Upper lip.
2. Mucous membrane of: Nasopharynx
Maxillary sinus
Soft palate
Tonsil
Hard palate.
Maxillary teeth and periodontal tissues.
 Branches
 Maxillary nerve gives off branches in four regions:
 1. Within the cranium
 2. In the pterygopalatine ganglion
 3. In the infraorbital canal
 4. On the face.
 Branches Within the Cranium: Middle
Meningeal Nerve
 Immediately after separating from trigeminal ganglion, the maxillary
nerve gives off a small branch, middle meningeal nerve.
 It travels with middle meningeal artery.
 It provides sensory innervation to the duramater of anterior half of
middle cranial fossa.
 Branches in the Pterygopalatine Fossa

i. Pterygopalatine nerves
ii. Zygomatic nerves
iii. Posterosuperior alveolar nerves.
 PTERYGOPALATINE NERVES
 Two short nerves, that suspend the pterygopalatine ganglion. They pass
through the ganglion into its branches.
 They also serve as a communication between pterygopalatine ganglion
and maxillary nerve.

 By way of ganglion, the maxillary nerve has the following branches.

1. Orbital branches: Supply periosteum of orbit.
2. Nasal branches: Supply mucous membranes superior and middle
conchae, the lining of posterior ethmoidal sinus and posterior portion of
nasal septum.
These convey postganglionic parasympathetic fibers from pterygopalatine
ganglion to nasal glands.
 Nasopalatine nerve (long sphenopalatine nerve) :

 a significant branch.
 It enters sphenopalatine foramen, crosses the roof of nasal cavity and
supplies its posteroinferior half.
 The nasopalatine nerve continues downwards reaching the floor of nasal
cavity and giving off its branches to anterior part of nasal septum and the
floor of nose.
 It enters incisive canal through which it passes into the oral cavity via the
incisive foramen. The right and left nasopalatine nerves emerge together
through this foramen and provide sensory innervation to palatal mucosa
in the region of premaxilla.
 Posterior superior lateral nasal nerves (short sphenopalatine nerves):
enter the sphenopalatine foramen and supply the posterosuperior
quadrant of lateral wall of nose.

 3. Palatine branches:
 a. Greater palatine nerves (anterior palatine nerves)
 b. Lesser palatine nerves (middle and posterior palatine nerves).
 These branches provide sensory innervation to hard and soft palate.
 These branches also convey postganglionic parasympathetic fibers from
pterygopalatine ganglion to palatal glands.
 Greater palatine nerves : It descends down through pterygopalatine
canal (greater palatine canal) of maxilla.
 It emerges on hard palate through greater palatine foramen supplying
sensory innervation to palatal soft tissues and bone.
 Anterior to first premolar it communicates with terminal fibers of
nasopalatine nerve.

 Lesser palatine nerve: These are sensory to soft palate. They descend
through lesser palatine foramina in palatine bone and pass backwards to
supply mucous membrane of soft palate.

 4. Pharyngeal branch: It provides sensory innervation to nasopharynx,

auditory (Eustachian) tube.
 ZYGOMATIC NERVES
 It provides sensory innervation to skin over zygomatic region.
 These nerves also convey postganglionic parasympathetic fibers from
pterygopalatine ganglion to lacrimal nerve and glands.
 It is a terminal branch. It carries out of pterygopalatine fossa and travels
anteriorly entering the orbit through inferior orbital fissure and runs
along the lower part of lateral wall of orbit.
 The zygomatic nerve enters zygomatic bone and divides into two
branches:
 Zygomaticotemporal nerve: supplies skin above zygomatic arch,
anterior part of temporal bone.
 Zygomaticofacial nerve: supplies skin over the prominence of cheek.
 POSTEROSUPERIOR ALVEOLAR
 NERVES
The main trunk of the maxillary nerve in the pterygopalatine fossa.
 Pass downwards through the pterygopalatine fossa and reach the
posterior surface of maxilla.
 Provide sensory innervation to:
 buccal gingiva in maxillary molar region; and adjacent facial mucosal
surfaces,
 mucous membrane of sinus and
 provides sensory innervation to alveoli, periodontal ligaments and
pulpal tissues of maxillary molars, with the exception of (25%)
mesiobuccal root of first molar.
 Branches in the Infraorbital
Canal
 In the infraorbital canal, the maxillary division gives two branches:
 1. Middle superior alveolar nerve.
 2. Anterior superior alveolar nerve.
 Middle superior alveolar nerve: Site of origin: infraorbital canal,
 Supplies adjacent mucosa of maxillary sinus; two premolars and
mesiobuccal root of first molar, periodontal tissues, buccal soft tissue
and bone in premolar region.

 Anterior superior alveolar nerve:

 After it exit from the infraorbital foramen it descends first lateral and
then inferior to infraorbital canal.
 Within the anterior wall of maxillary sinus, provides innervation to
central and lateral incisors and the canines as well as sensory
innervation to periodontal tissues, buccal bone and buccal gingiva of
these teeth.
 It reaches anteroinferior quadrant of lateral wall of nose and adjacent
floor of nose. It ends on nasal septum.
 In patients where middle superior alveolar nerve is absent, the anterior
superior alveolar nerve provides sensory innervation to premolars and
occasionally the mesiobuccal root of first molar.

 The innervation of roots of all teeth, bone and periodontal structures

are derived from terminal branches of larger nerves. These nerves
make network; termed as dental plexus.
 The superior dental plexus: These plexuses are composed of small
nerve fibers from the anterior, middle and posterior superior alveolar
nerves.
 Three types of nerves emerge from these plexuses are as follows:
1. Dental nerves: enter a tooth through apical foramen dividing into many
branches within the pulp.
2. Interdental branches: Provides sensory innervation to periodontal
ligaments of adjacent teeth through alveolar bone. It then enter the
gingiva to innervate the interdental papilla and buccal gingiva.
3. Inter radicular branches: periodontal ligament at root furcations.
 Branches on the Face
 Infraorbital nerve emerges on the face through infraorbital foramen
and divides into its terminal branches:

 Inferior palpebral: supply skin of lower eyelid with sensory

innervation to both surfaces of conjunctiva.
 External nasal/lateral nasal: provides sensory innervation to skin on
lateral aspect of nose.
 Superior labial: provides sensory innervation to skin and mucous
membrane of whole of upper lip
 Mandibular Nerve (V3)
 Mandibular nerve is the largest branch and nerve of first
(mandibular) branchial arch.
 And supplies the stuctures derived from that arch.
 Otic and submandibular ganglions are associated with this.
 It is a mixed nerve.
 Origin, Course and Branches
 Sensory root of the mandibular division: It originates at the inferior
part of trigeminal ganglion in the middle cranial fossa

 Motor root arises in motor cells located in pons and medulla

oblongata.
 The two roots emerge from the cranium, separately through the
foramen ovale, the small motor root lying medial to sensory root.
 They unite just outside or at the foramen ovale, and form the main
trunk of mandibular nerve.
 The main trunk remains undivided only for a short distance of 2 to 4
mm and then it divides into a “cat of nine tails.”
 The branches are:
 i. Small anterior trunk— all motor except one
 ii. Large posterior trunk— all sensory except one.

 Branches:
 In infratemporal fossa, it gives branches in three areas:
1. From undivided nerve
2. From anterior trunk
3. From posterior trunk.
 Branches from Undivided Nerve
 These are two branches:
 Meningeal branch
 Nerve to medial pterygoid.

 Meningeal branch (nervus spinosus): It passes upwards and re-enters

the cranium through foramen ovale.
 Here it supplies:
I. Cartilaginous part of eustachian tube
II. Middle cranial fossa; it supplies dura mater in the posterior half,
mastoid air cells.
 Nerve to medial pterygoid: It sinks into the deep surface of muscle.
 It has a branch that passes close to otic ganglion and supplies the two
tensor muscles, tensor velli palati and tensor tympani.
 Branches from Anterior Trunk
 The branches provide:
 Motor innervations to the muscles of mastication
 Sensory innervations to mucous membrane of cheek and buccal
gingiva of mandibular molars.
 The trunk runs forwards under lateral pterygoid muscle for a short
distance and then reaches the external surface of that muscle by
passing between its two heads. From this point it is known as long
buccal nerve (also long buccal nerve/buccinator nerve).
 The only sensory branch of anterior trunk.
 After passing from 2 heads of lateral pterygiod it runs downwards and
forwards.
 Emerges under the anterior border of masseter muscle and pierces the
buccinators.
 And supplies the skin of cheek, mucous membrane related to
buccinator. Also supplies labial aspect of gums molars and premolars.

 While under the lateral pterygoid muscle, the nerve gives off several
branches providing motor innervation to respective muscles.
 Deep temporal nerves
 Nerve to masseter
 Nerves to lateral pterygoid
 Branches of Posterior Trunk
 Primarily sensory, with a small motor component.
 Branches:
 i. Auriculotemporal
 ii. Lingual
 iii. Inferior alveolar nerve.
 Auriculotemporal nerve:
 It arises immediately beneath foramen ovale.
 It transverses upper part of parotid gland, between the TMJ and
external auditory meatus, crosses posterior part of zygomatic arch and
ascends close to superficial temporal artery.

 It has two parts:

 Auricular part: supplies the skin of tragus, upper part of pinna, external
acoustic meatus, tympanic membrane.
 Temporal part: supplies skin of temple.
 Lingual nerve:
 Second branch of posterior trunk of mandibular division.
 It runs anterior and medial to inferior alveolar nerve.
 It then continues downwards and forwards, deep to pterygomandibular
raphe and below the attachment of superior constrictor of pharynx, to
reach the side of the base of tongue, slightly below and behind and
medial to mandibular third molar.
 Here it lies just below the mucous membrane in the lateral lingual
sulcus.
 It then proceeds anteriorly in the floor of the mouth winding around the
submandibular (Wharton’s) duct, pass across the muscles of tongue to
the deep surface of sublingual gland, where it breaks up into its terminal
branches.
 It is sensory to anterior two-third of the tongue, for both general
sensation and gustation (taste) for this region.
 It is joined by chorda tympani, a branch of facial nerve about 2 cm
below base of skull deep to lower border of lateral pterygoid muscle.
 It also provides sensory innervation to mucous membrane of floor of
mouth and gingiva on lingual side of mandible.
 Inferior alveolar nerve
 Largest branch of mandibular division.
 It runs vertically downward and laterally to medial pterygoid and to the
sphenomandibular ligament.
 Then it enters mandibular canal at the level of mandibular foramen.
 Throughout its path, it is accompanied by inferior alveolar artery (a
branch of internal maxillary artery) and inferior alveolar vein. The artery
lies just anterior to the nerve.

 The nerve divides into terminal branches at the mental foramen:

I. Incisive nerve: Labial aspect of gums of canine and incisors.
II. Mental nerve: Skin of chin, skin & mucous membrane of lower lip.
 Mylohyoid nerve:
 Branches from inferior alveolar nerve prior to its entry into the
mandibular canal.
 It runs downwards and forwards in mylohyoid groove on medial
surface of ramus and along the body of mandible to reach the
mylohyoid muscle.
 It contains all the motor fibres from posterior division.
 Supplies to mylohyoid muscle and anterior belly of digastric.
GANGLIONS RELATED TO
TRIGEMINAL NERVE
 OTIC GANGLION
 Peripheral parasympathetic ganglion which relays secretomotar fibres
to parotid gland.
 Topographycally, it is
related to mandibular nerve Trigemin
al
but functionally it is a part ganglion

of glossopharyngeal nerve.

Otic
ganglion
 Trigeminal ganglion
 Crescentic or semilunar shaped sensory ganglion of 5th nerve.
 The ganglion lies on the trigeminal impression on the anterior surface
of petrous part of temporal bone near its apex and occupies a special
space of duramater called the trigeminal of Meckel’s cave.
 The central process of ganglion cells form the large sensory root while
the peripheral processes of ganglion cells
forms the three divisions of trigeminal nerve.
 Pterigopalatine ganglion
 This is the largest parasympathetic peripheral ganglion.
 Lies in the pterygopalatine fossa just below the maxillary nerve.
 Topographically it is related to maxillary nerve but functionally it
is connected to the facial nerve.

Submandibular ganglion
 Topographically it is related to lingual nerve but functionally it is
connected to the facial nerve.
 It is the relay station for secretomotor fibres to the submandibular
and subligual gland.
 Ciliary ganglion
 Parasympathetic ganglion placed in cource of occulomotor nerve.
 Lies near the apex of orbit.
 It has sensory, motor and sympathetic roots.
1. The sensory root comes from nesociliary nerve & contains
sensory fibres from the eyeball.
2. The motor root arises occulomotor nerve. It carries preganglionic
fibres from Edinger-Westphal nucleus to supply the sphincter
pupillae and ciliaris mucle.
3. The sympathetic root carries postganglionic fibres of superior
cervical ganglion to supply the blood vessels of eye ball and the
dilator pupillae.
CLINICAL ANATOMY
 Trigeminal Neuralgia
 ‘Tic Douloureux’ & ‘Fothergill’s disease’.
 It is defined as sudden, usually unilateral, severe, brief, stabbing,
lancinating, paroxysmal, recurring pain in the distribution of one or more
branches of 5th cranial nerve.
 Clinical Characteristics:
 Shock like pain, elicited by slight touching ‘trigger points’ which
radiates from that point, across the distribution of one or more branches
of the trigeminal nerve.
 Pain rarely crosses the midline: The pain is of short duration and lasts for
a few seconds.
 The location of the trigger points depends on which division of
trigeminal nerve is involved.
 In V1: the trigger zone usually lies over the supraorbital ridge of the
affected side.
 In V2: points are located on the skin of the upper lip, ala nasi or cheek or
on the upper gums.
 In V3: this is the most frequently involved branch. Trigger points are seen
over the lower lip, teeth or gums of the lower jaw. Tongue is rarely
involved.

 Treatment: Anticonvulsant drugs are most frequently used.

 Carbamazepine is the drug of choice in 85% cases, or combine with
Baclofen.
 Post herpetic neuralgia:
 It occurs after attacks of herpes zoster of the trigeminal nerve.
 It commonly involed ophthalmic branch.
 Para trigeminal or Readers syndrome:
 Characterizes by severe headache or pain in the area of trigeminal
distribution with signs of ocular sympathetic paralysis.
 Homolateral pain of head without vasomotor disturbances.
 frey syndrome / Gustatory sweating:
 It arries as a result of damage to auriculotemporal nerve and subsequent
innervation of sweat glands by parasympathetic salivary fibres.
 The patient typically exhibits flushing and sweating of the involves side
of the face, chiefly in temporal area, during eating.
 Motor examination:
 The mandibular nerve is tested clinically by asking the patient to clench
her/his teeth and then filling for the contracting masseter & temporalis
muscles on the two sides.
 If one masseter is paralysed, the jaw deviates to the paralysed side, on
opening mouth by the action of normal lateral pterygoid of opposite
side.
 The activity of pterygoid is tested by asking the patient to move the chin
from side to side.
 In injury to:
 Opthalmic nerve: loss of corneal blink reflex.
 Maxillary nerve: loss of sneeze reflex. As it is a afferent path
for sneeze reflex.
 Mandibular nerve: loss of jaw jerk reflex.
 A lesion of foramen ovale leads to paraesthesia along mandible,
tongue, temporal region and paraesthesia of mucles of
mastication. This leads to loss of jaw jerk reflex.
 Referred pain: In cases with cancer of tongue, pain radiates to the ear
and to the temporal fossa, over the distribution of auriculotemporal
nerve as both lingual and auriculotemporal nerve are branches of
mandibular nerve.
 As the lingual nerve lies in contact with mandible, medial to the third
molar tooth. In extraction of malposed wisdom tooth care must be taken
not injure lingual nerve. If injury occurs there is loss of all sensation
from anterior two-third of tongue.
 Inferior alveolar nerve: as it travels the mandibular canal can be
damaged by fracture of mandible, resulting in paraesthesia. This can be
assessed by testing sensation over the chin.
 During extraction buccal nerve may get involved by LA causing
temporary numbness of the cheek.
 Conclusion
 Since Trigeminal nerve is mixed nerve, supplies mainly head and neck
region. Hence as a dentist one should know throughly about intracranial
and extracranial course and distribution of Trigeminal nerve, to
diagnose the pathologies associated with Trigeminal nerve and for
appropriate treatment.
THANK YOU
Examination Of Trigeminal Nerve

1. Sensation Function

2. Motor Function

3. Corneal reflex

4. Test jaw jerk

 Sensation function Corneal
reflex
Use sterile sharp item on forehead, A clean piece of cotton wool
cheek, and jaw If any abnormality and ask the patient to look
present then go to test of thermal away gently touch the cornea
sensation and light touch with the cotton wool and the
patient will blink.
 Test jaw jerk (masserter reflex)
 Is a stretch reflex used to test the status of V nerve.
 Doctor finger on tip of jaw, grip patellar hammer halfway up shaft
and tap finger lightly,
 Normally patient as nothing is happens, or just a slight closure.
 Brisk in upper motor neuron lesions.
 Motor examination:
 The mandibular nerve is tested clinically by asking the patient to
clench her/his teeth and then filling for the contracting masseter &
temporalis muscles on the two sides.
 If one masseter is paralysed, the jaw deviates to the paralysed side,
on opening mouth by the action of normal lateral pterygoid of
opposite side.
 The activity of pterygoid is tested by asking the patient to move the
chin from side to side.
 Trigeminal Neuralgia
 ‘Tic Douloureux’ & ‘Fothergill’s disease’.
 It is defined as sudden, usually unilateral, severe, brief, stabbing,
lancinating, paroxysmal, recurring pain in the distribution of one or
more branches of 5th cranial nerve.
 Age of occurrence: 5th to 6th decade
 Sex predilection: female
 Side involved more frequently: right side
 Division of trigeminal nerve involved; most commonly : V3 > V2 > V1
 Pain rarely crosses the midline: The pain is of short duration and lasts
for a few seconds
 The paroxysms occur in cycles, each cycle lasting for weeks or
months and with time, the cycle appears closer and closer. With each
attack, the pain seems to become more intense and unbearable.
 The location of the trigger points depends on which division of
trigeminal nerve is involved.
 In V1: lies over the supraorbital ridge
 In V2: skin of the upper lip, ala nasi or
cheek or on the upper gums.
 In V3: lower lip, teeth or gums of the lower jaw.
Tongue is rarely involved.
 Provocated by obvious stimuli like
 Touching face at particular site
 Chewing
 Speaking
 Brushing
 Shaving
 Washing the face
 The characteristic of the disorder being that the attacks do not occur
during sleep.
 Sweet diagnostic 5 major criteria:

1. The pain is paroxysmal

2. The pain may be provoked by light touch to the face (trigger
zones)
3. The pain is confined to trigeminal distribution
4. The pain is unilateral
5. The clinical sensory examination is normal
 TREATMENT:
 Medical treatment
 Surgical treatment:
1. Peripheral injections
2. Peripheral neurectomy
3. Cryotherapy
4. Peripheral radiofrequency
5. Neurolysis(thermocoagulation)
6. Gasserian ganglion procedures
 Medical treatment

 Carbamazepine and phenytoin are the traditional anticonvulsants.

 The dosage of the drug used initially should be kept small to minimum
especially in elderly patients to avoid nausea, vomiting and gastric
irritation.
 Once the pain remission has being achieved the drug dose should be
kept at maintainance level or withdrawn and restarted if symptoms
reappear
 When carbamazepine is contraindicated clonazepam can be given
 Co-administration of phenytoin or baclofen is also advocated.
 Surgical treatment
 Peripheral Nerve Injections:
 Long acting anesthetic agents: without adrenaline bupivacaine
with or without corticosteroids.
 The selective nerve blocks can be given as an emergency measure,
where the patient is suffering quite a lot.
 Alcohol injections:
 The intraoral injection of 95% absolute alcohol in small quantities
(0.5 to 2 ml).
 Repeated alcohol injections should be avoided, as it causes local
tissue toxicity, inflammation and fibrosis.
 The results are variable. Sometimes it provides relief for a period
of 6 to 12 months or sometimes patient comes back with pain
immediately within short time span.
 Peripheral neurectomy (nerve Avulsion) :
 Oldest and the most effective procedure
 Simple
 Relatively reliable
 Indicated in patients in whom craniotomy is contraindicated due to
age, debility, limited life expectancy.
 Acts by interrupting the flow of a significant number of afferent
impulses to central trigeminal apparatus.
 Performed mostly on infraorbital, inferior alveolar, mental and
rarely lingual nerve.
 It has a disadvantage of producing full anesthesia or deep
hypoesthesia related dysfunction.
 Cryotherapy:

 Direct application of cryotherapy probe (nitrous oxide probe)

 Temperature colder than -60 ºC for 2-3 minutes
 Repeated three times
 Produces WALLERIAN degeneration without destroying the nerve
sheath.
 Peripheral radiofrequency neurolysis
thermocoagulation:

 Radiofrequency electrode that has the capacity to destroy the pain

fibres is used in this procedure.
 Temperature being 65 to 75 ºC for 1 to 2 minutes.
 Shown to induce pain remissions in 80% of cases.
 Advantages: Low morbidity in high risk/ elderly patients.
 GASSERIAN GANGLION PROCEDURS:

 Includes various procedures:

 1.Gycerol injection
 2.Thermocoagulation
 3.Ballon compression
 GYCEROL INJECTIONS:
 Absolute alcohol or phenol-glycerol mixture can be used as the
neurolytic agents.
 Agent is injected into meckel’s cave or in the ganglion.
 Causes damage to nerve cells presumably through dehydration.
 It induces pain relief in 80% of the cases.
 Also spares the ophthalmic division and the motor root. .
 THERMOCOAGULATION:
 A radiofrequency electrode that has the capacity to destroy pain fibres
is used.
 Alternating currents of high frequency is passed through the
electrode.
 It produces ionization in the biological tissues leads to coagulation of
tissues.
 BALLON COMPRESSION:
 A Fogarty catheter 1 to 2cm is advanced within the meckel’s cave
through foramen ovale.
 Inflated upto 0.75ml at the ventral aspect of the ganglion root for 1
minute.
 It destroys the root fibres.
 HERPES ZOSTER OPHTHALMICUS
 Caused by Varicella zoster
 Predilection for nasociliary branch of ophthalmic division of the
trigeminal nerve

 CLINICAL FEATURES:
 Cutaneous lesions: Rash
 Vesicle
 Pustule crust permanent scar
 Ocular lesions: Eyelid: Periorbital pain
 Oedema
 Hyperasthesia
 Conjunctivitis
 Scleritis
 Corneal scarring
 Glaucoma
 TREATMENT:
 Acyclovir 800mg 5 times /day within 4 days of onset of rash
 Analgesics
 Antibiotic ointments
 Systemic steroids 60mg/day
 Corneal grafting
 Para trigeminal or Readers syndrome:

 Characterizes by severe headache or pain in the area of ophthalmic

division of trigeminal nerve.
 Homolateral pain of head without vasomotor disturbances.
 Frey syndrome / Gustatory sweating:
 First described by frey.
 It is localised gustatory sweating in the area supplied by
auriculotemporal nerve.
 It arries as a result of damage to auriculotemporal nerve and subsequent
innervation of sweat glands by parasympathetic salivary fibres.
 The patient typically exhibits flushing and
sweating of the involves side of the face,
chiefly in temporal area, during eating.
 It can be commonly seen in:
 Penetrating wound of the parotid region
 Parotid surgery
 Mandibular & Zygomatic bone fractures
 TMJ surgery
 Treatment:
 Botox injection: reduce sweating
 Topical anti- perspirant (20% aluminium chloride solution)
 Application of an ointment containing an anti-cholinergic drug such
as 3% scopolamine
 Blockage of parasympathetic outflow by way of alcohol injection or
2%
lignocaine injections at various sites such as the otic ganglion &
the auriculo-temporal nerve.
 Partial parotidectomy.
 Trotter syndrome:
 In nasopharyngeal carcinoma, the tumor may extend laterally and
involve the sinus of Morgagni involving the mandibular nerve.
 This produces a triad of symptoms known as Trotter's Triad.
 These symptoms are:
 1) Conductive deafness (due to eustachian tube involvement)
 2) Ipsilateral immobility of the soft palate
 3) Trigeminal neuralgia
 LA Complications
 PSA Nerve Block:
 Hematoma
 Mandibular anesthesia
 Anterior Superior Alveolar Nerve Block (Infraorbital Nerve Block):
 Hematoma (rare) may develop across the lower eyelid and the tissues
between it and the infraorbital foramen.
 Injury to eye
 Nasopalatine nerve block.
 Inadequate palatal soft tissue anesthesia in the area of the maxillary
canine and first premolar during nasopalatine nerve block.
 Inferior Alveolar Nerve Block:
 Hematoma
 Excessive bleeding

 Mental Nerve Block:

 Hematoma
 Paresthesia of lip and/or chin. Hematoma: bilateral mental nerve blocks.

 Contact of the needle with the mental nerve as it exits the mental
foramen may lead to the sensation of an “electric shock” or to various
degrees of paresthesia (rare).
 During intraoperative procedure of implant placement one can
impinges on the inferior dental nerve & mylohyoid nerve.
 Inferior alveolar nerve: as it travels the mandibular canal can be
damaged by fracture of mandible, or during surgical removal of third
molar(0.41-7.5%) resulting in paraesthesia. This can be assessed by
testing sensation over the chin.
 As the lingual nerve lies in contact with mandible, medial to the third
molar tooth. In extraction of malposed wisdom tooth(0.06-11.5%) care
must be taken not injure lingual nerve. If injury occurs there is loss of
all sensation from anterior two-third of tongue.
 During extraction buccal nerve may get involved by LA causing
temporary numbness of the cheek.
 In injury to:
 Opthalmic nerve: loss of corneal blink reflex.
 Maxillary nerve: loss of sneeze reflex. As it is a afferent path for
sneeze reflex.
 Mandibular nerve: loss of jaw jerk reflex.
 A lesion of foramen ovale leads to paraesthesia along mandible,
tongue, temporal region and paraesthesia of mucles of mastication.
 Trigeminal nerve injury also occur due to:
 Ridge augmentation surgery
 Endodontic surgery
 Tumor resection
 Salivary gland and duct surgeries(Stone in the submandibular gland
duct)
 Biopsy procedures
 Orthognathic surgery: BSSO highest incidencce of neurosensory
disturbances.
 Maxillofacial trauma:
 Fracture of mandibular body and ramus
 LeFort fractures
 Fracture of condylar segment medially
 Mandibular angle, body and symphysis fracture

 Pathologic lesions:
 Surgical removal
 Use of Carnoy’s solution
 Conclusion
 Since Trigeminal nerve is mixed nerve, supplies mainly head and neck
region. Hence as a dentist one should know throughly about intracranial
and extracranial course and distribution of Trigeminal nerve, to
diagnose the pathologies associated with Trigeminal nerve and for
appropriate treatment.
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