UNIT 2A.

THE TRIGEMINAL NERVES The motor root joins the mandibular nerve
only, once it has exited the skull via the
foramen ovale.
THE TRIGEMINAL NERVE FIFTH
CRANIAL NERVE (N.V)

Innervation of the head and neck area, together

with other cranial and spinal nerves.

 Contains a large number of sensory

(afferent)and motor (efferent) neurons.
 Provides the sensitivity of the dentition,
the mucosa of the mouth, nose and
paranasal sinuses and the facial skin.
 The nerve also contains motor fibers that
innervate, among others, the masticatory
muscles.
ORIGIN
The trigeminal nerve emerges from the
middle of the pons, at the lateral surface of
the brainstem.
The nerve consists of two parts where: the
sensory fibers form a thick root and the
motor fibers form the much thinner motor
root.
These two roots run to the front of the
petrous part of the temporal bone where the
large sensory trigeminal ganglion (semilunar
or gasserian ganglion) lies in a shallow
groove surrounded by dura mater.
The trigeminal ganglion is formed by the
aggregation of cell bodies of sensory
neurons.
After the ganglion, three branches of the
trigeminal nerve can be distinguished: the
ophthalmic nerve (n.V1), the maxillary
nerve (n. V2) and the mandibular nerve (n.
V3).
 MOTOR ROOT OF THE TRIGEMINAL

 The motor root of the trigeminal

nerve consists of fibers that have
origin in the motor nucleus located
in the upper pons.
 The motor root passes below to the
foramen ovale, through which it
passes to join the mandibular
division immediately below the base
of the skull.
 The nerve is chiefly motor, and it’s
fibers supply the muscles of
mastication. It is often called the
masticator nerve.
MESENCEPHALIC ROOT OF THE
TRIGEMINAL
NERVE
 this nucleus serves as an afferent station
that receives proprioreceptive impulses
from the temporomandibular joint,
 the periodontal membrane, the maxillary
and mandibular teeth and the hard
SENSORY ROOT OF THE palate.
TRIGEMINAL ROOT  received afferent impulses from stretch
The fibers of the sensory root of the receptors in the muscle of mastication.
trigeminal nerve arise from the semilunar  these fibers are concerned with perfect
(gasserian) ganglion they enter the brain synchronization in controlling the biting
stem through the side of the pons. force of the jaws

The ganglion is crescent shaped. The

ganglion, with its unipolar neurons, forms
central and peripheral processes.
The peripheral branches form the
ophthalmic, maxillary, and mandibular
divisions of the nerve.
  the maxillary nerve or second
division of the trigeminal nerve,
is a sensory nerve.
 it begins at the middle of the
semilunar ganglion and leaves
the skull through the foramen
rotundum.
THE MANDIBULAR NERVE
innervates the skin of the lower
facial area, the mandibular dentition,
the mucosa of the lower lip, cheeks
and floor of the mouth, part of the
tongue and part of the external ear.
 the largest of the three
divisions of the trigeminal
 nerve, consists of two roots:
1. a large sensory root
arising from the semilunar
ganglion and

THE OPHTHALMIC NERVE 2. a smaller motor root

which passes beneath the
ganglion to unite with the
sensory root just after it
 Carries sensory information from
emerges through the
the skin of the forehead, the upper
foramen ovale.
eyelids and the nose ridge and the
mucosa of the nasal septum and
some paranasal sinuses.
 Enters the cranial part of the orbit
 Carries only sensory fibers
 The smallest of the three divisions,
and passes forward and enters the
orbit through the superior orbital
fissure.
THE MAXILLARY NERVE
 nerve innervates the skin of the
middle facial area, the side of
the nose and the lower eyelids,
the maxillary dentition, the
mucosa of the upper lip, the
palate, the nasal conchae and the
maxillary sinus SUMMARY OF FUNCTIONS OF THE TRIGEMINAL
NERVE

A. OPHTHALMIC DIVISION
1. Supratrochlear nerve- medial part of the
upper eyelid; lower medial part of the forehead;
conjunctive of the upper eyelid.
2. Supraorbital- skin of the upper eyelid; skin of
the forehead; the scalp to the vertex of the
skull, lining of the frontal sinus
3. Lacrimal nerve- skin of the upper eyelid;
lateral part of the eyebrow region; conjunctiva
of the lateral part of the upper eyelid
4. Nasociliary nerve
a. Long ciliary branch- eyeball and ciliary
ganglion
b. Infratrochlear nerve- upper and lower
eyelids; side of the nose; conjunctiva and the
lacrimal sac
c. Ethmoid branches
1. Anterior ethmoid branch- lining of the frontal
sinus and anterior ethmoid cells
2. Posterior ethmoid branch- lining of the
posterior ethmoid cells and the sphenoid sinus
d. Internal branches- anterior portion of the
septum and lateral walls of the nasal cavity
e. External nasal branch- tip of the nose
B. MAXILLARY DIVISION
1. In the central cavity the maxillary division
sends a sensory branch to the dura.
2. In the pterygopalatine fossa the maxillary
division gives off two branches
A. Zygomatic nerve and branches
1.) zygomaticofacial branch- skin over the
zygomatic bone
2.) zygomaticotemporal branch- skin of the side
of the forehead and of the anterior part of the
temporal region
B. Sphenopalatine (pterygopalatine)
1.) Orbital branches- periosteum of the orbit;
lining of the sphenoid sinus and posterior
ethmoid cells
2.) Greater palatine branch (anterior palatine)-
mucous membrane of the major part of the
hard palate and adjacent part of the soft palate
3.) Lesser palatine branches- mucous
membrane of the soft palate and tonsil area 4.)
Posterior lateral nasal branches- nasal conchae
5.) Nasopalatine branches- mucous membrane
of the lower and posterior part of the nasal
septum; premaxillary part of the hard palate
6.) pharyngeal branch- mucous membrane of
the nasopharynx; area behind the auditory tube
C. Posterior superior alveolar nerve
1.) gingival branches- buccal gingiva of the
upper molar region; mucous membrane of part
of the cheek
2.) alveolar branches- maxillary molars, except
the mesiobuccal root of the upper first molar
and their gingivae; mucous membrane of the
maxillary sinus
3.) In the infraorbital canal region
(a.) middle superior alveolar nerve maxillary
bicuspids; mesiobuccal root of the first molar,
lining of the maxillary sinus
(b.) anterior superior alveolar nerve- maxillary
incisors and cuspid; lining of the maxillary sinus
4.) Terminal branches on the face (infraorbital
branches)
(a.) inferior palpebral branches- skin of the
lower eyelid
(b.) lateral nasal branches- skin of the side of
the nose
(c.) superior labial branches- skin of the upper
lip
C. MANDIBULAR DIVISION
1. Nervus tentorii- dura of the posterior cranial
fossa; lining of the mastoid cells 2. Buccal (long
buccal) nerve- mucous membrane and skin of
the cheek region; Buccal gingiva of the
mandibular molar region
3. Auriculotemporal nerve- skin over the areas
supplied by the branches of the facial nerve
(zygomatic, buccal, and mandibular areas;
parotid gland (parotid branch);
temporomandibular articulation; skin lining the
external auditory meatus and lateral surface of
the tympanic membrane; skin and scalp over
the upper part of the external ear and the side
of the head up to the vertex of the skull
4. Lingual nerve- mucous membrane covering
the anterior two thirds of the tongue; mucous
membrane of the floor of the mouth and of the
lingual side of the mandibular gingivae;
submandibular and sublingual glands and their
ducts
- conveys special sense of taste from the
anterior two thirds of the tongue
- contains secretomotor fibers to the
submandibular and sublingual salivary glands
and the mucous glands I the floor of the mouth
5. Inferior alveolar nerve
a. Dental branches- lower molar and
bicuspid(mandibular) teeth and their
periodontal membranes
b. mental nerve- skin of the lower lip and chin
regions; mucous membrane lining the lower lip
region
. incisive nerve- incisors, cuspid teeth and their
periodontal me
Motor root of mandibular nerve
1. internal pterygoid nerve- innervates the
internal pterygoid muscle, the tensor veli
palatine muscle, and tensor tympani membrane
2. masseter nerve- masseter muscle
3. deep temporal branches- pass as the anterior
and posterior deep temporal branches to the
temporal muscle
4. external pterygoid- supplies the external
pterygoid muscle.
5. mylohyoid nerve- mylohyoid and the anterior
belly of the digastric muscle
For regional analgesia in the dental office
armamentarium should be complete and
efficient.
Categories
1. That used to obtain regional aesthesia
2. That used in the treatment of complications
ad emergencies
Equipment used to obtain Regional analgesia
1. Needles
- long needle is approx. 35 mm, a short one is
approx. 25 mm, and an extra-short
needle is approx. 12 mm. (for regional
anesthesia, infiltration anesthesia and
intraligamental anesthesia, respectively)
- are disposable and meant for single use only
- sections/parts- bevel, shank, hub, syringe
adaptor and syringe end
- gauge of 25–30 -The diameter of the needle is
measured in terms of gauge. The
smaller the gauge number, the larger the
needle’s diameter. A number higher
than 30 (i.e. very thin) should not be used,
because aspiration of blood is then no
longer possible.
- 25/27- rigid enough to be guided directly to
the large area without deviation, less
likely to penetrate smaller blood vessels,
aspiration is much easier and certain
through the larger lumen, safer and less likely to
break
- Made of platinum, stainless steel,
iridioplatinum alloy or platinum- ruthenium
- Stain less steel most widely used- rigid enough
to be easily guided during
insertion; maintain an extremely sharp point;
inexpensive enough to be discarded
after use with each patient; breakage rarely
occurs if properly handled; available
in a variety of lengths, gauges and styles;
withstands boiling and autoclaving
without corroding or weakening
2. Cartridges
- Glass tube sealed at one end by a rubber
stopper and the other end sealed by
an aluminum cap over rubber diaphragm
- Contents
1. anesthetic drugs or combination of drugs
2. Vasoconstrictor in various concentrations per
milliliter
3. A preservative- sodium bisulfite
4. Sodium chloride – make the solution isotonic
5. Distilled water in sufficient volume
6. Methylparaben- a germicide/ preservative,
found in some brands
Problems with Cartridges
1. Significance of bubbles- small bubbles may be
noted within the cartridge-1-2 mm
- harmless- usually are nitrogen gas to prevent
oxygen from entering the cartridge,
which would cause deterioration of the
vasoconstrictor
- large bubbles with or without plungers that
extend from beyond the end of the
cartridge (extruded) are caused by freezing; not
sterile
2. Extruded plungers
- That contain no bubbles, cartridge has been
left in chemical disinfecting solution
too long – contaminated and should be
discarded
3. Corrosion of aluminum caps
- Caused by immersion in chemical disinfecting
solutions that contain nitrite
antirust materials- should not be used
3. Syringes
-two different types of syringes: an insert type 3. Disengagement of harpoon from plunger
and a snap-in type during aspiration- excessive traction on the

-Both the insert- and snap-in-type syringes have piston when one is performing aspiration.
a spring mechanism that aids automatic Forceful action is not required but gentle

aspiration. backward motion will suffice

Conventional aspirating syringes 4. Surface deposits- accumulation of debris,

-A hermetically sealed 1.8 ml glass cartridge fits
into the syringe. Before the needle is
attached to the syringe, the piston of the
syringe is retracted and the cartridge is
saliva, and disinfectant solution interferes
with syringe function and appearance. Deposits
(sometimes resembling rust) can be
removed with thorough scrubbing

inserted, plunger end first, into the syringe.

Next the piston is pushed forward with
Self-aspirating syringe
moderate pressure until he the harpoon is
- Relies on elasticity of the rubber diaphragm of
firmly engaged I the plunger allowing
the cartridge to produce negative
aspiration when the piston is retracted. The
pressure necessary for aspiration.
needle is then affixed to the threaded portion
- Because there is no harpoon to be embedded
of the syringe. A few drops of solution are then
into the plunger of the cartridge,
expressed to ensure it is ready for use.
breakage of the glass during loading or
To unload the syringe, the cartridge is pulled
unloading of the syringe is not likely to
away from the needle as the piston is
occur
retracted until the harpoon disengages from the
plunger.

Common problems related to syringe handling Disposable aspirating syringe

include:

1. Leakage during injection- improper

attachment of the needle that results in an off - Composed of a sterile, disposable, needle-
syringe barrel combination and a
–center perforation o the diaphragm producing
n oval shaped rather than a round reusable plastic, barbed piston section

puncture

2. Cartridge breakage- from use of a badly won Jet injectors

syringe or a bent harpoon or the

application of excessive pressure when one is - spring loaded instrument capable of accepting
engaging the harpoon into the plunger any commercially available 1.8 ml

cartridge of anesthetic solution

- May be used to produce topical anesthesia
before needle insertion and may also
be used I place of needle injections to produce
infiltration anesthesia and for
nasopalatine, anterior palatine, and long buccal
nerve blocks
Accessory armamentarium
- suitable cotton applicators to dry the area of
the needle insertion, septic solution
and a topical anesthetic
Periodontal ligament injector
- Uses standard anesthetic cartridge and is
equipped with a pistol grip mechanism
allowing the solution to be expressed under
high. since the periodontal
membrane limits diffusion of the anesthetic,
high pressure is required to force the
solution to its site of action
- use of short 30-gauge needle- use of smaller
needle allows it to be more easily
and painlessly introduced into the periodontal
membrane space
Equipment used in the treatment of
complications and emergencies
A pair of hemostats or clamps- to immediately
grasp the protruding end of the needle in case
of
breakage
Emergency tray that contains the necessary
syringes, needles tourniquet, ampules and vials
of
emergency drugs
Oxygen and suitable equipment or
administering it by annual ventilator
Unit 3. Regional Analgesia (regional anesthesia,
local anesthesia)
Analgesia-refers to the loss of pain sensation
without loss of consciousness
Regional analgesia- loss of pain sensation over a
portion of the anatomy without the loss of
consciousness
Regional anesthesia- loss of pain sensation over
a portion of the anatomy without the loss of
consciousness; interruption of all other
sensations, including temperature, pressure and
motor
function.
Nerve Block- depositing a suitable local
anesthetic solution within a close proximity to a
main
nerve trunk within a close proximity to a main
nerve trunk and thus preventing afferent
impulses
from travelling beyond that point.
Field block- depositing solution in proximity to
the larger terminal branches so that the area to
be anesthetized is walled off or circumscribed
to prevent central passage of afferent impulses;
above the apex of the root
Local infiltration- small terminal nerve endings
in the area of the surgery are flooded with local
anesthetic solution rendering them insensible
to pain or preventing them from becoming
stimulated and creating an impulse; incision is Paraperiosteal (supraperiosteal injection)-
made through the same area in which the inserting the needle so that it comes into
proximity
solution has been deposited
with or contacts the periosteum; diffuse
Intraligamentary technique- intended to
through the periosteum and the underlying
provide single tooth anesthesia. Consist of
cortical
forcing the
bone; deposited beside the periosteum and not
anesthetic solution under pressure into the
above it.
periodontal membrane space of maxillary or

mandibular teeth; a type of infiltration

technique Intraosseous injection- injection into the
osseous structures; the intraosseous insertion
Topical analgesia- renders the free nerve
of the
endings in accessible structures (intact mucous
needle depends on the pathway into the bone
membrane, abraded skin, or the cornea of the
made by a more suitable instrument; utilized
eye) incapable of stimulation by the application
of when other methods fail to produce adequate
analgesia.
a suitable solution directly to the surface of the
area. Subperiosteal method- needles cannot be
inserted between the periosteum and the bone
METHOD OF INDUCTION
without danger of needle breakage or severe
Nerve blocks- performed by either the extraoral
pain to the patient; difficult to force the
or intraoral routes. In dentistry the intraoral
anesthetic
routes are used almost exclusively.
solution between the periosteum and the bone
Field block and local infiltration- classified
Interseptal technique-variation of the
according to the site of instrumentation.
intraosseous technique because a 22- or 23-
 Submucosal injections, gauge

 paraperiosteal injections, needle is forced gently into thin porous

interseptal bone on either side of the tooth;
 intraosseous injections, anesthetic
 interseptal injections, solution is then forced under pressure into the
 intraligamentary injections. cancellous bone; most effective in children and

Submucosal injection- inserting the needle young adults

beneath the mucosal layers and depositing the Factors in selecting the method of induction
solution so that it diffuses in this particular 1. Area to be anesthetized
plane
2. Profoundness required

3. Duration of anesthesia
4. Presence of infection 5. Patient, because of mental deficiencies, is
unable to cooperate
5. Age of patient
6. Major surgery makes regional analgesia
6. Condition of patient
unfeasible
7. Hemostasis

INDICATIONS FOR REGIONAL ANALGESIA

7. Anomalies make regional analgesia difficult or
Indicated when it is desirable or necessary for impossible
the patient to remain I the conscious state

while insensibility to [pain is produced in the

THEORIES OF REGIONAL ANESTHESIA
teeth and supporting structures

Advantages:
1. The primary site of local anesthetic action is
1. Patient remains awake and cooperative
the nerve membrane, its outer bimolecular
2. Little distortion of normal physiology, and the
lipoprotein layer
method is used to advantage on poor
2. The primary effect of local anesthetics is to
risked patient
decrease the permeability of the nerve
3. Low incidence of morbidity membrane to sodium

4. Patient may leave the office unescorted 3. The action of these agents is to stabilize the
nerve membrane in the polarized state
5. No additional trained personnel are
necessary thereby blocking nerve conduction

6. Techniques are not difficult to master
7. Less Percentage of failures
8. No additional expense to the patient
4. While other chemical may have the ability to
block the conduction, local anesthetics are
unique (reversible and no nerve damage)

9. Patient need not omit the previous meal

ARMAMENTARIUM
1. SYRINGE
Contraindications ---the most common is the non-disposable,
1. Patient refuses regional analgesia because of breech loading, metallic, cartridge type,
fear or apprehension aspirating syringe. (no wings or winged)

2. Infection rules out the use of regional

anesthesia

3. Patient is allergic to various local anesthetics

4. Patient is below age of reason

 Advantages: **periodontal ligament injection- requires for
pre-medication or an antibiotic prophylactic
 visible cartridge
depends if the patient needed that.
 aspiration with one hand
 autoclavable NEEDLES:
 rust resistant
 made of stainless steel
 long lasting
 needle gauge refers to the size of the
**pulling back on that thumb ring creates lumen
negative pressure  available in long or short depending
Disadvantages: upon injection
 should not be bent
 weight  should not be forced against resistance
 size, may be too big for small  should be changes after 3 or 4
operators insertions
Other types of syringes available NEEDLE GAUGE:
 breech loading plastic, cartridge type, The smaller the number, the larger the
aspirating
diameter of the lumen. A 30 gauge needle (very
 breech loading, metallic, cartridge
thin) has a smaller internal diameter than a 25
type, self aspirating
gauge needle.
 pressure for periodontal ligament
injection Advantages of slightly larger needles( 25 or 27
 jet gauge) are that there is less deflection, greater
 disposable: requires both hands for accuracy, less breakage and more success with
aspiration positive aspiration.
negative aspiration, no blood in the *you should never use a 30 gauge or an ultra
cartridge---great! short needles because those are more apt for
breakage

You’re aspirating 3 times for PSA and 3 times
for inferior alveolar because those are two most
common places where there would be a positive
aspiration.
*we use 25 gauge needle for our long needles in
the clinic while 27 gauge for short needles
*longer needles are going to be used when
penetrating thicker tissues such as the inferior
alveolar nerve
*shorter needles are recommended for any
infiltration techniques for mental block, psa,
msa, asa, for greater palatine and nasal palatine
*choice of needle depends on how much tissue
we want to penetrate
*short needles are approx.. 1 inch or 25 mm
and long needles ae approximately 1 5/8 or 40
mm.
CARTRIDGE
 glass cylinder containing local
anesthetic
 should be kept in original containers
 warmers are not needed nor
recommended
PROBLEMS WITH CARTRIDGES:
 bubble: small bubble or no bubble
is normal. If large bubble is
present , could be result of freezing
and should be discarded.
 Extruded stopper: could be result of
freezing. Should be discarded
 Rusted cap
 Broken cartridge: avoid forceful
engaging of harpoon
ANTISEPTICS: may use antiseptics prior to
injection to help reduce bacteria at the injection
site
 Not recommended to use antiseptics
that are tinctures because they contain
alcohol
 Betadine is commonly used
***wipe off with gauze, place topical anesthesia
for 1 min and wipe off with gauze again
*** it is not recommended to use any
antiseptics that are tinctures because they
contain alcohol that can cause a burning on
injection
TOPICAL ANESTHETIC
 Use sparingly for 1 minute prior to
injection. Provides about 2 mm of
anesthesia.
*** provides about 2-3 mm of
anesthesia, we’re not gonna rub it
because it can cause tissue swapping or
epithelial desquamation
 Do not rub as may cause tissue
sloughing
COTTON TIP APPLICATORS
use to apply topical anesthetics and for
pressure anesthesia of the palate
COTTON GAUZE IS USED TO WIPE TISSUES
PRIOR TO INJECTION TO RID AREA OF SURFACE
BACTERIA
HEMMOSTAT or cotton plier is not needed for
local anesthesia but should be handy to retrieve
a broken needle if needed. ***used only if
there is a broken needle.
ASSEMBLY OF SYRINGE
 Insert cartridge with piston retracted
 Engage harpoon
 Attach needle
 Remove cap and expel a few drops
 Recap using safety recapping device
 Maintain sterility at all times
 Disassemble at end and dispose of
needle in sharps container and
cartridge in separate approved
container.
THE ARMAMNTARIUM
  SYRINGE The ideal needle armamentarium for all
 NEEDLE intraoral injections consists of :
 CARTRIDGE
25 gauge long and 27 gauge short
ADDITIONAL ITEMS:
Applicator sticks Use of these recommended needles will ensure
Sterile gauze wipes that:
Topical anesthetic
 Aspiration of blood is possible and
Hemostat
reliable
What is found inside the local anesthetic  Breakage of the needle is extremely
cartridge? unlikely
 Patient comfort is maximized
North American anesthetic cartridges contain:
HOW DO YOU ASPIRATE?
1.8 ml of solution
General retraction of the thumb ring of the
A Cartridge of plain drug contains the following:
syringe pulls into the needle any fluid, air or
Local anesthetic tissue immediately surrounding the tip of the
needle. A positive aspiration occurs when blood
Sterile water
is seen in the syringe, to ensure a true negative
Sodium chloride aspiration, it should be performed twice
rotating your needle 45 degrees between
The ff. ingredients are found in local anesthetic aspirations
cartridge that contains a vasoconstrictor
WHAT IS THE PROPER TECHNIQUE OF
Epinephrine PREPRATION OF THE ARMAMETARIUM?
Sodium (metal) Bisulfite 1. Retract the piston
Shelf life for plain anesthetic is 36 months, if it 2. Insert the cartridge
contains epinephrine it is 18 months 3. Engage the harpoon with gentle finger
pressure
What needles are available for local anesthetic 4. Attach the needle
injections in dentistry? 5. Remove the cap
25/27 gauge-short and long 6. Expel a few drops of anesthetic to
ensure its proper flow
30 gauge-short and ultra short 7. Recap the needle, the syringe is ready
for use
Typical short dental needle is about 20 mm in
length from its tip to the hub What is the proper technique of unloading
the syringe?
Typical long needle is about 32 mm
To disassemble the syringe:
Ultra short is 10 mm
1. Retract the piston and remove the
**never insert a needle all the way into the
used cartridge
tissue to its hub unless it is absolutely essential
2. Unscrew the needle and dispose of
for the success of the injection
both in a sharps container
Proper technique for additional injections:

 Unscrew the needle

 Remove the empty cartridge
 Insert a new cartridge
 Embed the harpoon using gentle
pressure
 Reattach the needle
