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Trigeminal Nerve

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10 views55 pages

Trigeminal Nerve

Uploaded by

sonali
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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DEPARTMENT OF PROSTHODONTICS AND CROWNS & BRIDGES, ITS

DENTAL COLLEGE, GHAZIABAD

TRIGEMINAL NERVE

PRECEPTOR: Dr. Karvika Nayak Date: 11.11.2024


PRESENTER: Dr. Saleha Mansoob
INTRODUCTION

• 5th cranial nerve


• Largest of the twelve cranial nerves
• Composed of a small motor root and a larger(tripartite) sensory root
TRIGEMINAL GANGLION

• Sensory ganglion of fifth nerve.


• Made up of pseudounipolar nerve cells
• It is crescentic or semilunar in shape with its convexity directed
anterolaterally.
• The three divisions emerge from this convexity.
SURFACE MARKING
• In front of the preauricular point at a depth of about 5cm.

ASSOCIATED ROOT AND BRANCHES


• Central processes of the ganglion cells form the large sensory root of the
trigeminal nerve attached to pons at its junction with the middle
cerebellar peduncle.
• Peripheral processes form
Ophthalmic
Maxillary
Mandibular
• Small motor root attached to the pons superomedial to the sensory root.
• Passes under the ganglion from its medial to the lateral side and joins
mandibular nerve at foramen ovale.
OPHTHALMIC NERVE (V1)
OPHTHALMIC DIVISION

• Purely sensory.
• Smallest
• Leaves the cranium and enters the orbit through the superior orbital
fissure.
• Nerve trunk is 2.5 cm long.
MAXILLARY NERVE (V2)
MAXILLARY NERVE

PTERYGOPALATINE
CRANIUM
FOSSA

INFRAORBITAL CANAL FACE


INNERVATION
1.Skin
a.Middle portion of the face
b. lower eyelid
c. side of nose
d. upper lip
2. Mucous Membrane
a. Nasopharynx
b. Maxillary sinus
c. Soft palate
d. Tonsil
e. Hard palate
3. Maxillary teeth and periodontal tissues.
CONNECTIONS
MANDIBULAR NERVE (V3)
Nervous spinosus

Branches from
undivided nerve
Nerve to internal
pterygoid
INNERVATION

1. Sensory root
a. Skin
Temporal region
Auricula
External auditory meatus
cheek
Lower lip
Lower part of face ( chin region )
b. Mucous membrane
Cheek
Tongue
Mastoid cells
c. Mandibular teeth and periodontal tissues
d. Bone of the mandible
e. Temporomandibular joint
f. Parotid gland
2. Motor root
a. Masticatory
Masseter
Temporalis
Pterygoid medialis
Pterygoid lateralis

b. Mylohyoid
c. Anterior belly of digastric
d. Tensor tympani
e. Tensor veli palatini
CLINICAL EXAMINATION
3
EXAMINATION OF CORNEAL REFLEX :

• The Corneal Blink Reflex Test is done to asses


the Afferent (sensory arc) of the CN-V. Since the
Efferent (motor arc) is supplied by CN-VII.

• The corneal reflex is tested by closure of the


eyelids in response to irritation of the cornea by
touching with a sterile cotton applicator.

Hutchinson’s Clinical Methods 24th Edition


EXAMINATION OF SNEEZE REFLEX :

• Injury to maxillary nerve can result in


Sneeze Reflex loss, since the nasal
mucosa and olfactory receptors are
supplied by the V2 branches, giving off its
Afferent fibres to the same.

Hutchinson’s Clinical Methods 24th Edition


EXAMINATION OF JAW JERK REFLEX :

• Involves the contraction of Masseter and Temporalis


muscles, resulting in closure of mouth, when
patient’s jaw is tapped, since V3 gives its efferent
fibres whereas the afferent fibres are supplied by the
V2 division in ideal situations.
DISTURBANCES OF FIFTH CRANIAL NERVE
Park SH, Chang JW. Gamma Knife Radiosurgery on the Trigeminal Root Entry Zone for Idiopathic Trigeminal Neuralgia: Results and a
Review of the Literature. Yonsei Med J. 2020 Feb;61(2):111-119.
TRIGEMINAL NEURALGIA

• Tic doulourex, trifacial neuralgia, Fothergill’s disease.


• Mainly affects 2nd and 3rd divisions.
• Exhibits trigger zone, stimulation of which initiates paroxysm of pain.
• Pain is unilateral and lasts for few seconds to a minute.
• Pain itself is searing, stabbing or lancinating typre.
• Most cases are idiopathic.
• Older adults (females 3:2) more commonly involved.
TREATMENT
Pharmacology Management :
• CARBAMAZEPINE ( 100-200mg BDS )
• OXCARBAZEPINE ( 300 mg TDS )
• BACLOFEN ( 5-10 mg TDS )
Surgical Management :
Peripheral Procedures
• Cryotherapy of Peripheral branches.
• Peripheral Glycerol Inj.
• Alcohol Inj.
Central Procedures :
• Per-cutaneous Trigeminal Rhizotomy
• Microvascular Decompression (MVD)
• Gamma Knife Stereotactic Radiosurgery (GKS)
POST HERPETIC NEURALGIA

• Pain usually involves ophthalmic division of the 5th cranial N.


• Occurs after attacks of herpes zoster of the fifth nerve.
MANAGEMENT
AMITRIPTYLINE (10-25mg OD)
CARBAMAZEPINE ( 100-200mg BDS )
AURICULOTEMPORAL SYNDROME

• Frey’s syndrome, gustatory sweating.


• Result of damage to the ATN and subsequent reinnervation of sweat glands
by parasympathetic salivary fibers.
Management
Intracranial division of the nerve.
PROSTHODONTIC
CONSIDERATIONS
DISCUSSION :

• The article describes treatment of TN with the use of OEA, using Posselt’s law.
• Posselt’s Law : The movement area of the mandible in the sagittal and horizontal planes is
characteristic of the individual but varies in different persons. However, the border
movement paths are reproducible in the same individual.
• It is believed that some case of TMJ syndrome or atypical facial pain may be due to
entrapment neuropathies in the infratemporal fossa. The posterior trunk of the mandibular
division of the trigeminal nerve normally descends deep to the lateral pterygoid muscle.
• These findings support the hypothesis that a spastic condition of the lateral pterygoid
muscle may be causally related to compression of an entrapped nerve that leads to
numbness, pain, or both in the respective areas of nerve distribution.
DISCUSSION :

• The use of an anterior jig (AJ) is used achieve a superior


positioning of the condyles.
• This techniques use an anterior stop to disocclude
posterior teeth and eliminate possible tooth contact
interferences.
CONCLUSION :

1. The study of nerve entrapment in the Lateral Pterygoid Muscle by “Barry A (Loughner
BA)”finding that 3 of 52 dissections the three main branches of the posterior trunk
(lingual, inferior alveolar, and auriculotemporal nerves) were observed to pass through
the medial fibers of the lower belly of the lateral pterygoid muscle.

2. OEA was designed to release the contraction of lateral pterygoid muscle. This appliance
support condyle move back to the centric relation according to Posselt's border of
movement theory.

3. The article demonstrates the efficacy of occlusal equilibrium appliance (OEA) treatment
for chronic facial pain (CHP) and Trigeminal neuralgia (TN).

4. However, additional large-scale studies are necessary to validate the efficacy of OEA in
TN and CFP treatment.
MANAGEMENT :

1. Document any unusual response such as pain or


an electric shock like feeling during LA
administration.

2. If nerve injury is suspected, standardised test are


performed to document the level of neurosensory
functions as soon as the injury is suspected
(usually the day after surgery).

3. Signs of diminished sensation or failure of


senstation to improve on repeated testing
indicates normal sensations are not likely to
return.

4. Early referral allows the patient to undergo neural


repair within 4 months, minimising distal
degeneration of the nerve.
MANAGEMENT :

1. If an implant is potentially violating the canal, its depth should be decreased in bone
(unscrew a few turns) / left short of the canal or removed.

2. Since the altered sensational be due to an inflammatory reaction , steroid therapy or high
dose of NSAID’s (IBUPROFEN (800mg) TDS).

3. If improvement is noted at 3rd week, clinician can prescribe additional 3 wks of ant-
inflammatory drug treatment.

4. If however the sensation has not improved at 2 months, the prognosis is likely to be poor
and to be referred to micro neurosurgeon.
REFERENCES
1. B.D.Chaurasia. HumanAnatomy for Dental Students. New Delhi: CBS
Publishers&Distributors,.
2. S.F. Malamed. Handbook of Local Anaesthesia. New Delhi: Elsevier, 2012.
3. M.Glick. Burket’s Oral Medicine, Diagnosis and Treatment.12th ed, B.C.Decker Inc., 2014.
4. Shafer, Hine, Levy. Shafer’s Textbook of Oral Pathology. 8th ed. New Delhi: Elsevier.
5. Kuvatanasuchati J, Leowsrisook K. The simple treatment of chronic facial pain due to
trigeminal neuralgia with dental occlusal equilibration. Interdisciplinary Neurosurgery. 2019
Dec 1;18:100518.
6. Kraut RA, Chahal O. Management of patients with trigeminal nerve injuries after mandibular
implant placement. The Journal of the American Dental Association. 2002 Oct
1;133(10):1351-4.

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