trigeminal nerve and their disease222ptx

this presentation contain trigeminal nerve and their related disease in detail related to dentistry

1. TRIGEMINAL NERVE DR. SHANU KHAN MDS FIRST YEAR

2. CONTENT Introduction Trigeminal nerve ORIGIN COURSE &RELATIONS Ophthalmic division Maxillary division Mandibular division Nuclear columns of trigeminal nerve Branches and Anatomy Examination Of Trigeminal Nerve Clinical anatomy Conclusion References

3. INTRODUCTION NERVE NEURONE

4. DIFFERENCE B/W MYELINATED AND NON-MYELINATED NERVES

5. Trigeminal

6. INTRODUCTION Fifth and the Largest cranial nerve. It is the nerve of first brachial arch.

7. Nuclear columns are: 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.

8. Branchial Efferent column: Location – Upper pons Supply – Eight muscle derived from first branchial arch

9. Sensory components of V Nerve

10. Motor component

11. BRANCHES OF TRIGEMINAL NERVE

12. Ophthalmic Nerve (V1) Superior division of v nerve Purely sensory It divides into three branches: 1. Frontal 2. Nasociliary 3. Lacrimal . All these branches pass through superior orbital fissure into the orbit.

13. Course

14. FRONTAL BRANCH It is the largest branch; It passes through superior orbital fissure outside common tendinous ring. It divides into two branches:

15. SUPRAORBITAL: SUPRATROCHLEAR:

16. NASOCILIARY BRANCH: It passes the superior orbital fissure, medially within the common tendinous ring.

17. Divides into the following: 1. Long ciliary nerve sensory to eyeball 2. Nerve to ciliary ganglion 3. Infratrochlear Both eyelids, side of nose, lacrimal sac 4. Anterior ethmoidal - Middle and anterior ethmoidal sinus Medial internal nasal Tip of nose 5. Posterior ethmoidal – Sphenoidal air sinus posterior ethmoidal sinus

18. 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.

19. Maxillary Nerve (V2) It is purely sensory It is intermediate in size between ophthalmic and mandibular nerve . Supplies : derivatives of maxillary process and frontonasal process

20. Origin, Course and Branches Zygomatic nerve Nasopalatine nerve Pharyngeral nerve Greater palatine nerve Lesser palatine nerve Pterygopalatine nerve

21. 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 .

22. 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.

23. Origin, Course and Branches cat of nine tails.”

24. Examination Of Trigeminal Nerve Sensation Function Motor Function Corneal reflex Test jaw jerk

25. Sensation function Use sterile sharp item on forehead, cheek, and jaw If any abnormality present then go to test of thermal sensation and light touch 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.

26. 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.

27. Motor examination: The mandibular nerve is tested 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.

28. CLINICAL ANATOMY

29. 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 - 5th to 6th decade Sex predilection: female Side involved more frequently: right side

30. Division of trigeminal nerve involved; most commonly : V3 > V2 > V1 Pain rarely crosses the midline The location of the trigger points depends on which division of trigeminal nerve is involved.

31. Provocated by obvious stimuli like Touching face at particular site Chewing Speaking Brushing Shaving Washing the face The characteristic of the disorder - attacks do not occur during sleep .

32. Sweet diagnostic 5 major criteria: The pain is paroxysmal The pain may be provoked by light touch to the face (trigger zones) The pain is confined to trigeminal distribution The pain is unilateral The clinical sensory examination is normal

33. TREATMENT: Medical treatment Surgical treatment: Peripheral injections Peripheral neurectomy Cryotherapy Peripheral radiofrequency Neurolysis ( thermocoagulation )

34. Carbamazepine (600-1200mg/day) and phenytoin are the traditional anticonvulsants. When carbamazepine is contraindicated clonazepam can be given Co-administration of phenytoin or baclofen is also advocated. Medical treatment

35. 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. Alcohol injections: T he 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.

36. P eripheral neurectomy (nerve Avulsion) : Oldest and the most effective procedure Indicated in patients in whom craniotomy is contraindicated due to age , debility, limited life expectancy. Performed mostly on infraorbital , inferior alveolar , mental and rarely lingual nerve .

37. 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 .

38. 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 º C for 1 to 2 minutes. Shown to induce pain remissions in 80% of cases . Advantages: Low morbidity in high risk/ elderly patients.

39. 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 .

40. 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

41. Ocular lesions: Eyelid : Periorbital pain Oedema Hyperasthesia Conjunctivitis Scleritis Corneal scarring Glaucoma

42. TREATMENT: Acyclovir 800mg 5 times /day within 4 days of onset of rash Analgesics Antibiotic ointments Systemic steroids Corneal grafting

43. 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.

44. Frey syndrome / Gustatory sweating: First described by frey . It is localised gustatory sweating in the area supplied by auriculotemporal nerve. 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 .

45. 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   2% lignocaine injections  at various sites such as the  otic ganglion  & the  auriculo -temporal nerve.   Partial p arotidectomy .

46. 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

47. LA Complications PSA Nerve Block: Hematoma

48. As the lingual nerve lies in contact with mandible, medial to the third molar tooth. care must be taken not injure lingual nerve. If injury occurs there is loss of sensation from anterior two-third of tongue. During extraction buccal nerve may get involved by LA causing temporary numbness of the cheek.

49. 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.

50. 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.

51. 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.

52. Refernces BD Chaurasia’s Human Anatomy , 8 th Edition, Volume 4 Gray’s Anatomy, 41 st Edition Essentials of Human Anatomy by AK Dutta , 5 th Edition Shafer’s Textbook of Oral Pathology, 7 th Edition Martin SG. Burket’s Oral Medicine, 11th ed Grosenth , Faan G, Cruccu M. Practice Parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review). J Neuro 2008; 71:1183–1190

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