Trigeminal Nerve Anatomy

detailed anatomy of trigeminal nerve alonfg with its intracranial and extracranial course.

1. THE TRIGEMINAL NERVE Department of Oral & Maxillofacial Surgery NARSINHBHAI PATEL DENTAL COLLEGE AND HOSPITAL VISNAGAR Guided By : Dr. Arvind Agarwal , HOD and Professor Dr.Anil Mannagutti , Professor Dr.Shreedevi Bhoi Presented by: Dr. Harsh Patel 1 st year PG 11-Oct-13 Oral And Maxillofacial Surgery 1

2. Contents: Introduction Trigeminal Nuclei Functional Components Course & Distribution Trigeminal Ganglion Divisions of Trigeminal Nerve Clinical Examination of V Nerve Applied Anatomy Summary References 11-Oct-13 Oral And Maxillofacial Surgery 2

3. INTRODUCTION The largest cranial nerve It is mixed nerve ( sensory and motor ) Sensory to – Skin of face -Mucosa of cranial viscera -Except base of tongue and pharynx Motor to –Muscles of Mastication -Tensor ville palatini,Tensor tympany -Anterior belly of digastric - Mylohyoid 11-Oct-13 Oral And Maxillofacial Surgery 3

4. NUCLEI 11-Oct-13 Oral And Maxillofacial Surgery 4

5. TRIGEMINAL NUCLEI A  cranial nerve nucleus  is a collection of  neurons  ( gray matter ) in the  brain stem  that is associated with one or more cranial nerves .  Axons  carrying information to and from the cranial nerves form a  synapse  first at these  nuclei . Lesions occurring at these nuclei can lead to effects resembling those seen by the severing of nerve(s) they are associated with . 11-Oct-13 Oral And Maxillofacial Surgery 5

6. SENSORY NUCLEI : 1.Mesencephalic nucleus Cell body of Pseudounipolar neuron Relay proprioception from muscles of mastication, Extra ocular Muscles, Facial muscles. Situated in Midbrain just latetral to Aqueduct. 11-Oct-13 Oral And Maxillofacial Surgery 6

7. 2.Principal sensory nucleus - Lies in Pons lateral to Motor nucleus Relays touch sensation 11-Oct-13 Oral And Maxillofacial Surgery 7

8. 3.Spinal nucleus- Extends from caudal end of principal sensory Nucles in pons to 2 nd or 3 rd spinal segment It relys Pain and Temperature 11-Oct-13 Oral And Maxillofacial Surgery 8

9. MOTOR NUCLEUS : Innervates muscles of mastication and tensor tympani and tensor palatini Derived from first branchial arch. Located in pons medial to principle sensory nucleus. 11-Oct-13 Oral And Maxillofacial Surgery 9

10. 11-Oct-13 Oral And Maxillofacial Surgery 10

11. 11-Oct-13 Oral And Maxillofacial Surgery 11

12. FUNCTIONAL COMPONENTS Sensory Root Motor Root 11-Oct-13 Oral And Maxillofacial Surgery 12

13. SENSORY ROOT GENERAL SOMATIC AFFERENTS- Face, Scalp, Teeth, Gingiva , Oral, Nasal, Cavities, Para nasal sinus, Conjunctiva and Cornea. Pain, temp, light touch touch , pressure proprioception Trigeminal gang. Bypasses trigem gang. sensory root. 11-Oct-13 Oral And Maxillofacial Surgery 13 Spinal nuc . Principal sen nuc . Mesencephalic CNS

14. MOTOR NUCLEUS MOTOR ROOT MANDIBULAR NERVE Muscles of mastication Tensor tympani Masseter Tensor palatini Lateral & Medial Pterygoids Temporalis CNS 11-Oct-13 Oral And Maxillofacial Surgery 14 MOTOR ROOT

15. 11-Oct-13 Oral And Maxillofacial Surgery 15

16. COURSE & DISTRIBUTION Both motor and sensory root are attached ventrally to junction of pons and middle cerebellar peduncle with motor root lying ventromedially to the sensory root. Pass anteriorly in middle cranial fossa to lie below tentorium cerebelli in cavum trigeminale , here motor root lies inferior to sensory root. 11-Oct-13 Oral And Maxillofacial Surgery 16

17. Sensory root connected to postromedial concave border of the trigeminal ganglion. Convex antrolatateral margin of the ganglion gives attachment to the 3 div. Of the trigeminal nerve. 11-Oct-13 Oral And Maxillofacial Surgery 17

18. 11-Oct-13 Oral And Maxillofacial Surgery 18

19. 11-Oct-13 Oral And Maxillofacial Surgery 19

20. 11-Oct-13 Oral And Maxillofacial Surgery 20

21. Motor root turns further inferior with sensory component of V3 to emerge out of foramen Ovale as Mandibular nerve. Ophthalmic and Maxillary division emerges through Superior orbital fissure and foramen Rotundum respectively. 11-Oct-13 Oral And Maxillofacial Surgery 21

22. 11-Oct-13 Oral And Maxillofacial Surgery 22

23. GANGLION 11-Oct-13 Oral And Maxillofacial Surgery 23

24. THE TRIGEMINAL GANGLION SEMILUNAR OR GASSERIAN GANGLION. Cresentric in shape with convexity anterolaterally . Contains cell bodies of pseudounipolar neurons. LOCATION : lies in a bony fossa at apex of the petrous temporal bone on floor of middle cranial fossa , just lateral to posterior part of lateral wall of the cavernous sinus. 11-Oct-13 Oral And Maxillofacial Surgery 24

25. COVERINGS : covered by dural pouch = MECKLES CAVE or CAVUM TRIGEMINALE. cave lined by pia and arachnoid thus the ganglion is bathed in CSF . ARTERIAL SUPPLY : Ganglionic branches of Internal Carotid Artery, middle meningeal artery and accessory meningeal artery. 11-Oct-13 Oral And Maxillofacial Surgery 25

26. 11-Oct-13 Oral And Maxillofacial Surgery 26

27. RELATIONS: SUPERIORLY : * superior petrosal sinus * free margin of tentorium cerebelli INFERIORLY : *motor root * greater petrosal nerve * petrous apex * foramen lacerum MEDIALLY : * posterior part of lateral wall of cavernous sinus * Internal Carotid Artery with its sympathetic plexus LATERALLY : * uncus of temporal lobe * middle meningeal artery and vein * nervous spinosum 11-Oct-13 Oral And Maxillofacial Surgery 27

28. 11-Oct-13 Oral And Maxillofacial Surgery 28

29. DIVISIONS OF TRIGEMINAL NERVE 1. Ophthalmic nerve 2. Maxillary nerve 3. Mandibular nerve 11-Oct-13 Oral And Maxillofacial Surgery 29

30. 11-Oct-13 Oral And Maxillofacial Surgery 30

31. OPTHALMIC NERRVE 11-Oct-13 Oral And Maxillofacial Surgery 31

32. OPHTHALMIC NERVE Smallest division. Sensory only Supplies : eyeballs, conjunctiva, lacrimal gland, mucosa of nose and paranasal sinus, skin of forehead eyelid and nose 11-Oct-13 Oral And Maxillofacial Surgery 32

33. Course: 3 branches in ant part of cavernous sinus superior orbital fissure lat wall cavernous sinus orbit lacrimal , nasocilliary , frontal emerges from trigeminal ganglion 11-Oct-13 Oral And Maxillofacial Surgery 33

34. 11-Oct-13 Oral And Maxillofacial Surgery 34

35. LACRIMAL NERVE Smallest Passes into orbit through lateral compartment of the Superior orbital fissure outside the tendinous ring. Receives communicating branch from Trochlear nerve branch of Opthalmic 11-Oct-13 Oral And Maxillofacial Surgery 35

36. Receives branch from Zygomaticotemporal nerve branch of maxillary Sensory to lateral conjunctiva, Upper Lid, lacrimal gland Post synaptic parasympathetic fibers from pterigopalatine ganglion to lacrimal gland ( parasym secretomotor ). 11-Oct-13 Oral And Maxillofacial Surgery 36

37. 11-Oct-13 Oral And Maxillofacial Surgery 37

38. FRONTAL NERVE Largest Enters orbit through lateral part of superior orbital fissure outside tendinous ring Passes forward between roof of orbit and Levator Palpebral Superioris Supratrochlear Nerve Divides midway into : Supraorbital Nerve 11-Oct-13 Oral And Maxillofacial Surgery 38

39. 11-Oct-13 Oral And Maxillofacial Surgery 39

40. SUPRATROCHLEAR N SUPRAORBITAL N Smaller nerve Medial branch Receives communication branches from infratrochlear nerve Curves around superomedial margin of orbit Larger nerve lateral branch Passes through supraorbital notch Divides in medial and lateral branches. 11-Oct-13 Oral And Maxillofacial Surgery 40

41. supplies: median conjunctiva, Upper Lid and lower part of forehead Lies between frontalis and corrugator supercilliary muscles Lies beneath frontalis muscle Supplies: conjunctiva, scalp upto vertex , mucous membrane of frontal sinus 11-Oct-13 Oral And Maxillofacial Surgery 41

42. NASOCILLIARY NERVE Purely Sensory Passes through middle part of superior orbital fissure within the tendenious ring . Runs along medial wall of orbit between Superior Oblique and Medial Rectus Divides into Anterior Ethmoidal and External Nasal 5 branches in orbit. 11-Oct-13 Oral And Maxillofacial Surgery 42

43. 1. Short Clliary Nerves : Fibers reaches eyeball and also contains fibers from Cilliary Ganglion 2. Long Cilliary Nerves : 2 or 3in no. supply to Iris and Cornea. 3. Post Ethmoidal Nerve : passes through posterior ethmoidal foramen to supply the Ethmoid and Sphenoid PNS. 4. Infratrochlear Nerve : appears on face above med angle the eye. Supplies to skin of lacrimal sac and caruncle . 11-Oct-13 Oral And Maxillofacial Surgery 43

44. 11-Oct-13 Oral And Maxillofacial Surgery 44

45. 11-Oct-13 Oral And Maxillofacial Surgery 45

46. l 5. Anterior Ethmoidal Nerve : larger terminal branch Course: anterior ethmoidal foramen and canal into anterior cranial fossa on sup surf of cribriform plate Through slit lat to crista galli into nasal cavity Med internal nasal branch lat internal nasal branch Supplies ant nasal septum supplies ant part lat nasal cavity emerges as external nasal nerve to skin of ala,vestibule,and tip of nose 11-Oct-13 Oral And Maxillofacial Surgery 46

47. MAXILLARY NERVE 11-Oct-13 Oral And Maxillofacial Surgery 47

48. 11-Oct-13 Oral And Maxillofacial Surgery 48

49. MAXILLARY NERVE Second division of trigeminal nerve Pure sensory Supplies derivatives of maxillary process and frontonasal process 11-Oct-13 Oral And Maxillofacial Surgery 49

50. Course: 11-Oct-13 Oral And Maxillofacial Surgery 50 Trigeminal ganglion-> Middle cranial fossa Lateral wall of cavernous sinus Foramen rotundum Pterigopalatine fossa In groove on posterior surface of maxilla Through inferior orbital fissure into orbit as INFRA ORBITAL N Through infraorbital foramen on face

51. After leaving foramen rotundum it moves anteriorly in the uppermost part of pterygopalatine fossa . As it passes through pterygopalatine fossa it also gives branches to sphnopalatine ganglion, posterior superior alveolar nerve and zygomatic branches. 11-Oct-13 Oral And Maxillofacial Surgery 51

52. It then moves laterally and moves in a groove on posterior surface of maxilla. Then enters orbit through infra orbital fissure and moves through infra orbital groove where it is called as Infraorbital nerve and emerges on face from infra orbital foramen. 11-Oct-13 Oral And Maxillofacial Surgery 52

53. 11-Oct-13 Oral And Maxillofacial Surgery 53

54. 11-Oct-13 Oral And Maxillofacial Surgery 54

55. BRANCHES IN MIDDLE CRANIAL FOSSA: - Meningeal branch :Travels along the middle meningeal artery and provides sensory innervation to cranial dura matter. 11-Oct-13 Oral And Maxillofacial Surgery 55

56. IN PTERIGOPALATINE FOSSA: 1. Ganglionic branches - Arises as 2trunks.Trunks join to form single root within pterygopalatine ganglion. Gives Orital branches,Palatine branches,Pharyngeal branches,Nasal branches Gives postganglionic secretomotor fibers to lacrimal gland via zygomaticotemporal and lacrimal . 11-Oct-13 Oral And Maxillofacial Surgery 56

57. 2. Orbital branch : Supplies periosteum of orbit 3. Nasal branch : Supplies to mucosa of superior and inferior conchae , posterior ethmiodal sinus and posterior portion of nasal septum. It also includes Nasopalatine branch. -It passes across roof of nasal cavity downwards and forwards lying between mucosa and periosteum of nasal septum. -Reaches to floor of nasal cavity n give branch to anterior part of nasal septum and floor of nasal cavity. -Enters Incisive canal and enters oral cavity through insicive foramen -It provides sensation to palatal mucosa of premaxilla region. 11-Oct-13 Oral And Maxillofacial Surgery 57

58. 11-Oct-13 Oral And Maxillofacial Surgery 58

59. 11-Oct-13 Oral And Maxillofacial Surgery 59

60. 4. Palatine branch : Arise as greater palatine (anterior) and lesser palatine (middle and posterior) -Greater palatine nerve descends through pterygopalatine canal from the ganglion and emerges from greater palatine foramen of hard palate. -Then moves anteriorly between mucoperiostem and hard palate upto 1 st premolar supplying sensory innervation to palatal soft tissue and bone. Then communicates with nasopalatine -Middle palatine and posterior palatine emerges from lesser palatine foramen and supply soft palate and tonsilar region respectively. 11-Oct-13 Oral And Maxillofacial Surgery 60

61. 11-Oct-13 Oral And Maxillofacial Surgery 61

62. 5. Pharyngeal branch : It leaves the posterior part of pterygopalatine ganglion and passes through the phryngeal canal It is distributed to the mucous mambreane of the nasal part of pharynx, posterior to eustachian tube. 11-Oct-13 Oral And Maxillofacial Surgery 62

63. POST. SUPERIOR ALVEOLAR NERVE -It arises from the main trunk of maxillary nerve in the petrygopalatine fossa just before the nerve enters the inferior orbital canal - Usually arises as 2 trunks. - Passes downwards and crosses the pterygoplatine fossa reaching infratemporal surface of maxilla. - 1 st trunk continues downwards on posterior surface of maxilla and provide sensory innervation to buccal gingiva in maxillary molar region and adjacent facial mucosal surface 11-Oct-13 Oral And Maxillofacial Surgery 63

64. -2 nd trunk enters maxila through PSA canal to travel to posterolateral wall of maxillary sinus providing sensory innervation to sinus mucosa. Continuing downwards this also provides sensory innervation to alveoli, PDL, pulp of molar tooth. 11-Oct-13 Oral And Maxillofacial Surgery 64

65. 11-Oct-13 Oral And Maxillofacial Surgery 65

66. Zygomatic nerve : A. Zygomaticofacial nerve -Appears on face through foramen in the zygomatic bone -Supplies skin on prominence of cheek B. Zygomaticotemporal nerve -Appears in infratemporal region thru foramen in zygomatic bone -Supplies skin of temporal region after peircing temporal fascia 2 cm above zygoma -Gives communicating branch to lacrimal N suppling parasymp . Secretomotor fibres to lacrimal gland . 11-Oct-13 Oral And Maxillofacial Surgery 66 It enters orbit through infra orbital fissure.

67. IN THE INFRAORBITAL CANAL 1. Middle superior alveolar nerve : runs along lat wall of maxilla Participates in superor dental plexus Supplies premolars. 2. Anterior superior alveolar nerve : Runs in canal in ant wall of maxilla= canalii sinosus #Dental branches # nasal branches Joins sup dental plexus lat wallof inf meatus to to supply canines opening of max sinus . 11-Oct-13 Oral And Maxillofacial Surgery 67

68. 3. FACIAL BRANCHES : 1.P alpebral nerves-pierces Orbicularis Occuli and supplies skin of lower lid. 2.N asal branches-supplies skin of lat wall nose and mobile part of septum. 3. S uperior labial nerve- forms infraorbital plexus supplies skin and mm of upper lip, cheek and labial glands . 11-Oct-13 Oral And Maxillofacial Surgery 68

69. 11-Oct-13 Oral And Maxillofacial Surgery 69

70. MANDIBULAR NERVE 11-Oct-13 Oral And Maxillofacial Surgery 70

71. MANDIBULAR NERVE Largest Mixed Nerve of 1 st branchial arch Motor root- from motor nucleus in pons sensory root- gasserian ganglion a a small ant. Division exit through foramen ovale in greater wing of sphenoid from trunk which remain 2-3 mm undivided in infratemporal fossa travels between lat. Pterygoid and Otic ganglion laterally and tensor palatine medially anteriorly to med. Meningeal A. large post. division 11-Oct-13 Oral And Maxillofacial Surgery 71

72. 11-Oct-13 Oral And Maxillofacial Surgery 72

73. Branches Trunk (undivided) Nervous Spinosus Nerve to medial Pterygoid Anterior Division Massetric Nerve. Deep temporal Nerve. Nerve to lateral Pterygoid Buccal Nerve. Posterior Division Auriculo Temporal Nerve Inferior. Alveolar Nerve Lingual Nerve. 11-Oct-13 Oral And Maxillofacial Surgery 73

74. Branches from trunk Before dividing into anterior and posterior division it gives 2 branches during its 2-3mm path 1. Nervous spinosus or Meningeal branch of Mandibular nerve It reenters cranial cavity through foramen spinosus along with middle meningial artery Supply Dura matter of middle cranial fossa and mastoid air sinus 2. Nerve to mededial Pterygoid Supplies medial pterygoid Through Otic ganglion without interruption to Tensor tympani Tensor palatini 11-Oct-13 Oral And Maxillofacial Surgery 74

75. 11-Oct-13 Oral And Maxillofacial Surgery 75

76. Branches from the anterior division The anterior division is significantly smaller than posterior. After dividing from the main trunk. It runs anteriorly and below the lateral pterygoid muscle to over its upper border. After this the nerve is buccal nerve . reach its external surface of muscle by either passing through two heads or winding 1. Nerve to lateral pterygoid : It enters the deep surface of the muscle. It may arise as independent branch or may arise in common with buccal nerve. 11-Oct-13 Oral And Maxillofacial Surgery 76

77. 2. Massetric nerve - Emerges at the upper border of the lateral pterygoid just in front of TMJ. Passes laterally through mandibular notch along with massetric vessels, and enters the deep surface of masseter , also suppliesTMJ 3. Buccal nerve -is the only sensory branch of ant div. travels betwn 2 heads of lat pterygoid and emerges in cheek at ant border of masseter . Supplies skin and mucous membrane of cheek. 4. Deep temporal nerve -There are anterior and posterior deep temporal nerves. Passes between skull, and enters deep surface of the temporalis . Anterior is often a branch of buccal nerve and the posterior may arise in common with massetric nerve. 11-Oct-13 Oral And Maxillofacial Surgery 77

78. 11-Oct-13 Oral And Maxillofacial Surgery 78

79. Branches Of Posterior Division 11-Oct-13 Oral And Maxillofacial Surgery 79

80. 1.Auriculotemporal nerve- Arises from 2 roots which run backwards and encircle the middle meningeal artery and form single trunk The trunk passes posterior to lateral pterygoid between neck of mandible and sphenomandibular ligament superior to 1 st part of maxillary art. Lies behind the TMJ close to the parotid Ascends behind superficial temporal vessels and then in temporal region divides into superficial temporal branches. 11-Oct-13 Oral And Maxillofacial Surgery 80

81. 11-Oct-13 Oral And Maxillofacial Surgery 81

82. Branches Of Auriculotemporal Nerve Auricular branches - supply tragus, upper part of aurical,roof of external auditory meatus , anterosuperior part of tympanic membrane Superficial temporal branches -supply skin of temple It also supply sensory and secretomotor to parotid. Articular branches -supply the TMJ. 11-Oct-13 Oral And Maxillofacial Surgery 82

83. 2. Inferior alveolar nerve: Is mixed nerve Runs vertically downwards medial to lateral ptrygoid and lateroposterior to lingual nerve. Then moves between the sphenomandibular ligament and medial surface of mandibular ramus Enters mandible through mandibular foramen to run in a bony canal below the teeth 11-Oct-13 Oral And Maxillofacial Surgery 83

84. Branches: 1. Mylohyoid : Arises just before the nerve enters mandibular foramen.It pierces the sphenomandibular ligament along with mylohyoid muscle and runs in the mylohyoid goove . Supplies to mylohyoid muscle and anterior belly of digastric . It is also sensory to skin on inferior and anterior surface surfaces of mental protuberence . It may provide sensory innervation to mandibular incisors . There is also evidence that mylohyoid supply to mesial root of mandibular frist molar. 2. Branches to lower teeth and gums . 3. Mental nerve : It exits canal and divides into three branches innervating skin of chin and skin and mucous membrane of the lower lip. 4. Incisive nerve : It remains within the canal and form plexus that innervates pulpal tissue of first premolar canine and incisors through dental branches. 11-Oct-13 Oral And Maxillofacial Surgery 84

85. 11-Oct-13 Oral And Maxillofacial Surgery 85

86. 11-Oct-13 Oral And Maxillofacial Surgery 86

87. 3.Lingual nerve: lies anterior to inferior alveolar n between lateral pterygoid and tensor palatini receives chorda tympani (SVA) Emerges from inferior border of lateral pterygoid to lie between ramus and medial pterygoid in peterygomandibular space moves downwards and forwards deep to pterygomandibular raphe between origins of supirior constrictor and mylohyoid Reach to side of base of tongue 1 cm below and behind 3 rd molar just below mucous membrane of lateral lingual sulcus 11-Oct-13 Oral And Maxillofacial Surgery 87

88. 11-Oct-13 Oral And Maxillofacial Surgery 88 -Then proceeds anteriorly across the muscles of tongue ,looping medially and downwards to submandibular duct to deep surface of submandibular gland where it break in terminal branches -Sensory to anterior 2/3 of tonge along with special sensation also sensory to floor of mouth and gingiva on lingual side of mandible.

89. 11-Oct-13 Oral And Maxillofacial Surgery 89

90. 11-Oct-13 Oral And Maxillofacial Surgery 90

91. 11-Oct-13 Oral And Maxillofacial Surgery 91

92. Branches of lingual nerve and its communications: 1.Chorda tympani 2.Communications with submandibular ganglion 3.Hypoglossal nerve 11-Oct-13 Oral And Maxillofacial Surgery 92

93. Ganglia Associated With The Trigeminal Nerve 1. Cilliary Ganglion : connected with nasocilliary nerve by ganglionic branches in orbit, non synapsing sensory for orbit 2. Pterygopalatine Ganglion : connected to maxillary nerve in infratemporal fossa sensory to orbital septum, orbicularis and nasal cavity, max sinus, palate, nasopharynx . 3. Otic Ganglion : betwn trunk of mandibular n and tensor palatini , nerve to med pterygoid passes thru but does not synapse in the ganglion. 4. Submandibular Ganglion : related to lingual n, rests on hypoglossus supplies post gang. Parasym secretomotor fibres to submandibular and sublingual gland. 11-Oct-13 Oral And Maxillofacial Surgery 93

94. CUTANEOUS DISTRIBUTION OF TRIGEMINAL NERVE Each half of face is supplied by 13 cut N 1motor and 12 sensory Of 12 sensory : 11 are from trigeminal N 1 is c2 greater auricular N Branches of trigeminal N 5 from ophthalmic: lacrimal supraorbital supratrocheal infratrochlear external nasal 11-Oct-13 Oral And Maxillofacial Surgery 94

95. 11-Oct-13 Oral And Maxillofacial Surgery 95

96. 3 from maxillary N: infra orbital N zygomaticofacial N zygomaticotemporal N 3 from mandibular N: buccal N auriculotemporal N mental N DIVISIONAL SUPPLY: From lat canthus to vertex- ophthalmic N From angle of mouth to vertex- mandibular N Between the two areas-maxillary N 11-Oct-13 Oral And Maxillofacial Surgery 96

97. Examination of trigeminal nerve 11-Oct-13 Oral And Maxillofacial Surgery 97

98. Examination of trigeminal nerve 1- Sensation Function 2- Motor Function 3- Corneal reflex 4- Test jaw jerk 11-Oct-13 Oral And Maxillofacial Surgery 98

99. Sensation function use sterile sharp item on forehead, cheek, and jaw If any abnormality present we test the thermal sensation and light touch 11-Oct-13 Oral And Maxillofacial Surgery 99

100. Corneal reflex a clean piece of cotton wool and ask the patient to look away gently touch the cornea with the cotton wool and the patient will blink. 11-Oct-13 Oral And Maxillofacial Surgery 100

101. Test jaw jerk Doctor finger on tip of jaw, grip patellar hammer halfway up shaft and tap finger lightly usually nothing happens, or just a slight closure. 11-Oct-13 Oral And Maxillofacial Surgery 101

102. APPLIED ANATOMY 11-Oct-13 Oral And Maxillofacial Surgery 102

103. 1. Trigeminal Neuralgia – Tic Douloureux Sudden, usually unilateral severe, brief, stabbing lancinating , recurring pain in the distribution of one or more branches of the 5th Nerve 11-Oct-13 Oral And Maxillofacial Surgery 103

104. 2. TRIGEMINAL NEUROPATHY sensory loss of face or weakness of the jaw muscles causes- sjogren syndrome herpes zoster, leprosy meningioma,schwanomma 11-Oct-13 Oral And Maxillofacial Surgery 104

105. 4. HERPES ZOSTER OPHTHALMICUS : Recurrent neurocutaneous inf. In opth . Div. of trigeminal dermatome, most freq. affecting nasociliary branch HHV3 / vericella zoster Gasserian ganglion ophthalmic nerve Supraorbital N. Infraorbital N. Supratrochlear N. Infratrochlear N. Nasal N. 11-Oct-13 Oral And Maxillofacial Surgery 105

106. 11-Oct-13 Oral And Maxillofacial Surgery 106

107. 5. Cavernous sinus syndrome Cavernous sinus syndrome Multiple cranial neuropathies Exophthalmos , ocular motor defects, sensory loss in V1 and / or V2. Pupils may be spared or involved. causes: bacterial thrombophlebitis actinomycosis rhinocerebellar mucormycosis aspergillosis tolosa hunt syndrome neoplasms vascular lesions 11-Oct-13 Oral And Maxillofacial Surgery 107

108. 6.Gradenigos syndrome Petrous bone osteitis due to otitis media Characterized by I/L trigeminal N palsy ( Va , Vb ) retro orbital pain I/L sixth N palsy. 11-Oct-13 Oral And Maxillofacial Surgery 108

109. Conclusion Since Trigeminal nerve is mixed nerve, suplies mainly head and neck region. Hence as a Oral and Maxillofacial surgeon one should know throughly about itracranial and extracranial course and distribution of Trigeminal nerve,to diagnose the pathologies associated with Trigeminal nerveand for appropriate treatment. 11-Oct-13 Oral And Maxillofacial Surgery 109

110. Refrences : Greys anatomy Snells anatomy Head and Neck Anatomy-BD Chourasia Textbook of Local Anesthesia- Stenly F Malamed 11-Oct-13 Oral And Maxillofacial Surgery 110