1.PRESENTED BY DR. SHEETAL KAPSE1st YEAR, P.G. STUDENT

2. Largest among all12 cranial nerve Roots - sensory & motor 3 divisions fromsensory root- ophthalmic- maxillary- mandibularTRIGEMINAL NERVE 3. Trigeminal Nuclei The sensory trigeminal nerve nuclei largest of the cranial nerve nucleiextend through whole of the brainstem.1. The mesencephalic nucleus- proprioception2. The chief sensory nucleus (or "pontinenucleus" or "main sensory nucleus" or"primary nucleus") touch3. The spinal trigeminal nucleus pain & temperature. 4. MAXILLARY NERVE Middle or 2nd branch fromgasserian or trigeminal ganglion. Purely sensory. 5. From middle part oftrigeminal ganglion.ORIGIN 6. COURSE 7. BRANCHESWithin cranium In pterygopalatine fossa In infraorbital canal On faceMAXILLARY NERVEMiddle meningealnerve Inferior palpebral Lateral nasal Superior labial MSA(middle superioralveolar nerve)ASA(anterior superioralveolar nerve)ZygomaticPSA(posteriorsuperioralveolar)PterygopalatineZygomaticotemporalzygomaticofacialOrbitalNasalPalatinePharyngeal 8. WITHIN CRANIUMMiddle meningeal nerve- travels with middle meningeal artery- supplies duramater 9. IN PTERYGOPALATINE FOSSA1. ZYGOMATIC NERVEenters orbit throughinferior orbitalfissure ,it gives 2 brancheswithin inferior orbitalfissure 10. Zygomaticotemporal Nerve- Runs along lateral orbital wall- Appears in infratemporal region- Supplies skin of temporal region afterpiercing temporal fascia 2 cm above thezygoma.- Gives communicating branch to lacrimalnerve.- Supplies parasympethetic Secretomotorfibres to lacrimal gland. 11. Zygomaticofacial nerve Appears on face through foramen in the zygomatic bone Supplies the skin over prominence of cheek. 12. 2. PTERYGOPALATINE NERVEThese are communications between pterygopalatineganglion & maxillary nerve 13. ORBITAL BRANCH 14. NASAL BRANCHSupplies mucous membrane of superior & middle conchae lining of posterior ethmoidal sinus posterior part of nasal septum 15. NASOPALATINE BRANCH 16. PALATINE BRANCH GREATER PALATINE /ANTERIOR PALATINEBRANCH LESSER PALATINE(MIDDLE & POSTERIORPALATINE) 17. PHARYNGEAL BRANCHLeaves the posterior part ofpterygopalatine ganglionpharyngeal canalSupplies the mucousmembrane of nasopharynx &posterior part of eustachian tube. 18. 3. POSTERIOR SUPERIOR ALVEOLARNERVE (PSA)generally 2 branches are thereIt runs along with internalmaxillary artery. 19. POSTERIOR SUPERIORALVEOLAR NERVE 20. IN INFRAORBITAL CANAL1. MIDDLE SUPERIOR ALVEOLAR NERVE 21. 2. ANTERIOR SUPERIOR ALVEOLAR NERVEAnterior superior alveolarnerveArises 6-10 mm beforeinfraorbital grooveDescends in anteriorwall of maxillary sinus. 22. DENTAL PLUXES 23. ON FACE1. INFERIORPALPEBRAL2. LATERALNASAL3. SUPERIORLABIAL 24. 1. Trigeminal ganglion 25. 2.CILIARY GANGLION:sensory for orbit 26. 3. PTERYGOPALATINE GANGLION:(Synonym: ganglion pterygopalatinum,meckels ganglion, nasal ganglion,sphenopalatine ganglion) 27. PTERYGOPALATINE GANGLION: connected to maxillary nerve ininfratemporal fossasensory to orbital septum, orbicularis and nasal cavity ,maxillary sinus , palate , nasopharynx. 28. 4. OTIC GANGLION:between trunk of mandibular nerve and tensor palatinisupplies post ganglionicParasympethetic secretomotorfibres to parotid gland. 29. related to lingual nerve, rests on hyoglossus musclesupplies post ganglionicParasympetheticsecretomotor fibres tosubmandibular andsublingual gland.5. SUBMANDIBULAR GANGLION: 30. Applied anatomyCauses of injury to trigeminal nerve 1. Maxillofacial surgical proceduresOrthognathic surgeriesthird molar odontotomysalivary gland surgerieshead & neck preprosthetic surgeriesTreatment of bening & malignent lesions2. Trauma & facial fractures3. Dental implant placement4. Endodontic therapy5. Tratment of pathology (specially periapical)6. During administration of local anesthesia 31. TRIGEMINAL NEURALGIA TIC DOULOUREUX relatively common paroxysm of sudden intense,shocking, stabbing onset offacial pain Involves One or more areas ofdistribution Of the trigeminal Nerve maxillary and mandibulardivisions are commonly involved 32. local lesions-ophthalmic division : acute glaucomafrontal sinusitismaxillary division : cariescarcinoma of maxillaempyema of maxillary sinusmandibular division : cariescarcinoma or ulcer of tongueTRIGGER ZONE 33. Surgical procedures for treatmentof trigeminal neuralgia -Radiofrequency rhizotomyMicrovascular decompression of the nerve at ponsPercutaneous glycerol rhizotomyBalloon compression rhizotomyPeripheral RhizotomyMicrosurgical Rhizotomy 34. Meckels Cave The average heightof this oval mouthwas found to be 4.2mm (range 3-5 mm) the average widthwas 7.6 mm (range6-8 mm). located- 12 mmSource -Turkish NeurosurgeryOfficial journal of neurological societyAnatomy of Meckels Cave and the Trigeminal Ganglion: Anatomical Landmarks for a Safer Approachto Them2012, Volume 22, Number 3, Page(s) 317-323 35. Procedure Description in ShortThrough the entry point2.5cm lateral to the corner of the mouth, aspecially designed needle with thin stylet was passed into foramen ovale. 36. The balloon catheter was introduced through the needle and navigatedinto Meckels cave. 37. External Sinus SurgeryAndrew H. Murr, MDJOURNAL OF AMERICAN RHINOLOGY SOCIETYRevised 6/2011care.american-rhinologic.org/external_sinus_surgery 38. Caldwell-Luc Approach: 39. ECTOPIC INFRAORBITAL NERVE IN AMAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLY DANGEROUSVARIANT FOR SINUS SURGERYP. Mailleux1, O. Desgain2, M.I. Ingabire1Evidence in Health and Social Care(Online journal)www.rbrs.org/dbfiles/journalarticle_0814.pdfWorld Neurosurg. 2011 Sep-Oct;7 2010,93: 308-309 ; discussion 266-7 40. Trauma To Bones Of Skull & Face 41. Trauma to bones of skull & facemalar fractures-Trauma to infraorbital margin may causesensory loss of infraorbital skin. 42. MAXILLARY SINUSINFECTIONS Infections of the maxillary sinus may causeinfraorbital pain or may cause referred pain to other structuressupplied by Vb (e.g. upper teeth). 43. Maxillary teeth abscesses The roots of the maxillary teeth (especiallythe second molars)are intimately related to themaxillary sinus. Root abscesses are painful. 44. Hay fever This is usually allergic, but the symptoms could be produced byinvolvement of parasympathetic fellow travellerswith the maxillary nerve. 45. Nerve injury in orthognathicsurgery Neurosensory impairment in the greater palatine andinfraorbital nerves may be encountered after maxillaryosteotomies.herkules.oulu.fi/isbn9514269934/html/x486.htmlCorrection of dentofacial deformities withorthognathic surgery: Outcome of treatmentwith special reference to costs, benefits and risksChapter 2. Review of the literature(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).2.5. Complications and adverse effects of orthognathic surgerySource - 46. Maxillary antrum tumours Malignant tumours of the mucous lining of themaxillary antrummay expand into the orbit,damaging branches of V(infraorbita)l.anaesthesia over the facial skin. The orbital contents may also be displaced causingproptosis and/or a squint. 47. TUMOR SPREAD ALONGINFRAORBITAL NERVEWorld Neurosurg. 2011 Sep-Oct;76(3-4):335-41;discussion 266-7 (online journal)medinfo.ufl.edu/year1/trigem/top_clin.htmlA case of BASAL CELL CARCINOMA 48. Histopathology -A case of BASAL CELL CARCINOMAtypical nuclear palisading at the peripheral layer of the tumor 49. Nasopharyngeal CarcinomaSource Maxillary Nerve Involvement in Nasopharyngealcarcinoma, American Journal of RoentgenologyAJR:167, November 1996V.F.H.Chong1 and Y.F. Fan 50. A, Axial unenhanced T1-weighted MR image showsenlargement of right pterygopalatine fossa (asterisk).Notenormal fat-filled left pterygopalatine fossa (arrow). 51. B, Axial contrast-enhanced T1-weighted MR image revealstumor enhancement in pterygopalatine fossa withspread into cavernous sinus (arrowheads). 52. C, Coronal unenhanced T1-weighted MR image shows enlargeingright maxillary nerve of intermediate signal intensity(black arrow). Note tumor infiltration of right vidian canal (whitearrow). 53. E, Axial unenhanced Ti-weighted MR image inferior to D shows tumorinfiltration in pterygopalatine fossa andinfratemporal wall of right maxillary sinus (arrow) and extension intoinfratemporal fossa (asterisk). 54. G, Coronal CT scan (bone window) shows tumor inpterygopalatine fossa (asterisk). Note enlarged maxillarynerve groove (thick arrow) and normal left maxillary nerve (thinarrow). 55. Trigeminal neurinomas extending into multiplefossae: surgical methods and review of theliterature. We present a 38-year-old female with a giant dumbbell-shapedtrigeminal neurinoma originating primarily in the middle cranialfossa, extending to the infratemporal and posterior fossae through theforamen ovale and Meckels cave, respectively. Because of the large tumour extension into the Infratemporal Fossa, acombined skull base approach (zygomatic infratemporal -transmandibular) was utilised for tumour removal, with a subsequentexcellent outcome.Journals of Neurosurgery 1999 Aug;91(2):202-11.Source - Trigeminal neurinomas extending into multiple fossae: surgical methods and review ofthe literature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands. 56. Trigeminal NeurinomaProf. Dr. med. Henry W. S. Schroeder,Universittsmedizin GreifswaldA case report by -Clinic & polyclinic for neurosurgeryMicroscopic (A) and endoscopic (B) image of trigeminal neurinoma. Infront of the tumor one can see vestibular nerves (short arrow).(A) (B) 57. THE MRI IMAGES SHOW THE TUMOUR IN THECEREBELLOPONTINE ANGLE 58. The final inspection shows complete tumorremoval.Removal of tumorTumor under endoscopic visual controlTumor under the operating microscopevisual control 59. Postoperative MRI imagesshow complete tumorremoval 60. Dumbbell trigeminal schwannoma in a child:complete removal by a one-stage pterionalsurgical approach.PATIENT ANDMETHODS: A 6-year-old girl presentedwith tiredness, dysarthricspeech and cerebellarsymptoms. Imaging studiesSource - Dumbbell trigeminal schwannoma in a child: complete removal by a one-stage pterionalsurgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, The Netherlands.www.ncbi.nlm.nih.gov/pubmed/15770515 61. One-stage surgerywas performed bypterional craniotomy.The tumour was firstdebulked in the middlefossa, then peeledfrom the wall of thecavernous sinus,followed by extirpationof the tumour from theposterior fossa. Histopathological 62. Trigeminal neuropathysensory loss of face or weakness of the jaw musclescauses- SLE, sjogren syndromeherpes zoster, leprosymeningioma, schwanommaWallenberg syndrome vertebral artery occlusion infarction of lateral medullasymptoms - ipsilateral facial sensory loss,ipsilateral horners,ipsilateral IX,X,XI palsyipsilateral cerebellar ataxia ,contralateral sensory loss 63. Herpes zoster ophthalmicus: HHV3 / vericella zoster most frequently affecting nasociliary branch Gasserian ganglionophthalmic nerveSupraorbital Nerve. Infraorbital N.Supratrochlear Nerve.Infratrochlear Nerve.Nasal Nerve. 64. visual morbidity Pain precedes skin lesion clinical feature ishemifacial unioccular Cutaneous lesionsMaculopapular rashVesiclePustulesCrustPermanent scar 65. Cont. III, IV, VI th cranial NERVE palsy Progressive proptosis Post. Herpetic neuralgias TreatmentPHN- anlgesic, anti depressants, trigeminal rhizotomy andstellate ganglion block. 66. STURGE WEBER SYNDROMEencephalotrigeminal angiomatosisport-wine stainrare congenital neurological & skin disorderoften associated with port-wine stains of theface, glaucoma, seizures, mental retardation 67. Neurotrophic keratitis Occurs due to partial or complete corneal anaesthesia due to loss of sensoryinnervation by the trigeminal N. There is impaired response to corneal microtrauma as a result of impairedregeneration and healing of corneal epithelium Causes: infections - HSV, VZV, leprosytraumatic V N injuryablation of gasserian ganglionchemical burnstopical anaesthatic abuse,betablockrs,NSIDScontact lens wearsystemic: DM, stroke, brainstemhaemorrhage, aneurysmcongenital 68. Raeders paratrigeminal syndrome Oculosympathetic paresis with pain in distribution oftrigeminal Nerve.Pt. with episodic chronic painPain and headache Trigeminal hyperasthesia seen in area supplied bypost ganglionic fibers. 69. Raeders paratrigeminal syndromePulling pain over the left zygomatic regionwhich radiated two days later to an area behind& below the left ear.Pain presented at mourning & reoccurred atnigtht .Wooshing & buzzing sound in left ear.Numbness over the left side of face.Blurred vision.Unable to bite.Left nostril appeared blocked. 70. Cavernous sinus syndrome- multiple cranial neuropathies- exophthalmos, ocular motordefects, horners syndrome,sensory loss in V1 and / or V2.Cavernous sinus syndrome is amedical emergency, requiringprompt medical attention,diagnosis, and treatment 71. Potential causes of cavernoussinus syndrome include 1. metastatic tumors,2. direct extension of nasopharyngealtumors,3. meningioma,4. pituitary tumors,5. aneurysms of the intracavernouscarotid artery6. cavernous-carotid arteriovenous fistula,7. bacterial infection causing cavernoussinus thrombosis,8. aseptic thrombosis,9. fungal infections. 72. Gradenigos syndrome Petrous bone osteitis due tosuppurative otitis media Characterized by -- ipsilateral trigeminal Nervepalsy (Va, Vb)- retro orbital pain- ipsilateral sixth N palsy. 73. Clinical testing Test skin sensation of lower eyelid, cheek and upper lip. Three simple clinical tests for trigeminal nerve function:(1) sensation: apply gentle touch, pinpricks, or warm or coldobjects to areas supplied by the nerve and note responses;(2) reflex: try the jaw jerk and eye and sneeze reflexes;(3) motor function: test the patients ability to chew and workagainst resistance and observe contraction of the massater andtemporal muscles by visual examination and digital palpation. 74. Purpose of test -1. Is there any loss of senssation ????2. Where the lesion is present ????- peripheral branches- gasserian ganglion 75. 1. For touch2. For pain & temperature 76. Causes 1. Lesion of ganglion.2. Lesion of sensoryroot.Loss of sensationof half Face+Ipsilateral half of bodyOpposite thalamus 77. Loss of sensationof half Face+opposite half of bodyBrain stemorOpposite thalamus 78. Causes 1. Partial lesion of ganglion (HZV)2. Trauma3. Cavernous sinus syndrome 79. Pontine lesion affecting chief sensory nucleus.causes 1. Vascular diseases2. Pontine tumor3. Brain stem displacement ddue to large tumor 80. Causes lesions of descending root dueto1. syringobulbia2. foramen magnum tumor3. bulbar vascular accidents 81. In case of anomalous development or occlusion ofposterior inferior cerebellar artery loss of pain & temperature in- ipsilateral half face- contralateral opposite half of body 82. Causes 1. Vascular lesion2. Multiple sclerosis3. Herpes infection 83. RESOURSES Text book Malamads local anesthesiaHarrisons principle of internal medicinePetersons principle of oral & maxillofacial surgeryAnesthesia/ dentoalveolar surgery/ office management-by Frost, Harsh & Levin Online sources -Turkish NeurosurgeryOfficial journal of neurological society, 2012, Volume 22, Number 3, Page(s) 317-323Anatomy of Meckels Cave and the Trigeminal Ganglion: Anatomical Landmarks fora Safer Approach to ThemJOURNAL OF AMERICAN RHINOLOGY SOCIETY, Revised 6/2011External Sinus Surgery,Andrew H. Murr, MD 84. Evidence in Health and Social Care,World Neurosurg. 2011 Sep-Oct;7 2010, 93: 308-309 ; discussion 266-7ECTOPIC INFRAORBITAL NERVE IN A MAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLY DANGEROUS VARIANT FOR SINUS SURGERYP. Mailleux1, O. Desgain2, M.I. Ingabire1(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al. 1991).2.5. Complications and adverse effects of orthognathic surgeryWorld Neurosurg. 2011 Sep-Oct;76(3-4):335-41; discussion 266-7 (online journal),TUMOR SPREAD ALONG INFRAORBITAL NERVEJournals of Neurosurgery 1999 Aug;91(2):202-11.Trigeminal neurinomas extending into multiple fossae: surgical methods and review of theliterature.2005 Nov;21(11):1008-11. Epub 2005 Mar 16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands. 85. Dumbbell trigeminal schwannoma in a child: complete removal by a one-stagepterional surgical approach. childs Nerv Syst. 2005 Nov;21(11):1008-11. Epub 2005 Mar16.Department of Neurology, University Medical Center St Radboud, Nijmegen, TheNetherlands.Maxillary Nerve Involvement in Nasopharyngeal carcinoma,American Journal of RoentgenologyAJR:167, November 1996V.F.H.Chong1 and Y.F. Fan 86. Online other sourceshttp://smj.sma.org.sg/0902/0902smj10.pdfhttp://www.rbrs.org/dbfiles/journalarticle_0814.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/21986433http://www.medizin.unigreifswald.de/neurohttp://www.medizin.uni-greifswaldwww.tsdocs.org/downloads/CranialNerves.pdf