DENTAL GROSS
ANATOMY
CASE 2.2
HISTORY
A 62-year old woman complained to her dentist about sudden
bouts of excruciating pain on the left side of her face.
The bouts had started ~ 2 months previously and had been
increasing in severity. The stabbing pains lasted 15-20 seconds,
occurred several times a day and were so severe that she had
once contemplated suicide.
After examination the dentist told her there was no dental cause
for the pain and he referred her to a physician.
PHYSICAL EXAMINATION
The woman told the physician that the onset of the pain was
sometimes triggered by chewing or a cold wind blowing on her
upper lip.
When asked to point out the area where the pain occurred she
pointed to her left upper lip and cheek. She indicated that the
pain also radiated to her lower eyelid, lateral side of the nose and
the inside of the mouth.
The physician applied firm pressure over the patient’s left cheek
and over her infraorbital area, but detected no tenderness
indicative of maxillary sinusitis.
The physician did detect acute sensitivity to touch on the left
upper lip and to pin-pricking over the entire left maxillary region.
No abnormality of sensation was found in the forehead or
mandibular regions.
1. What is the diagnosis?
TRIGEMINAL NEURALGIA
(“TIC DOULOUREUX”)
2. Which branch of what major nerve
supplies the area of skin and
mucous membrane where the
paroxysms (sudden recurring
attacks) of stabbing pain were
felt?
Maxillary n. (V2)
Infraorbital n.
Zygomaticofacial n.
Zygomaticotemporal n.
3. Through what foramen and what
bone does this nerve leave the
skull?
Greater wing of sphenoid
Foramen rotundum
(for V2)
4. Why was no abnormality of
sensation found in the forehead
region? In the mandibular region?
Ophthalmic n. (V1)
Maxillary n. (V2)
Mandibular n. (V3)
5. Where are the cell bodies of the
affected nerve located?
Trigeminal
ganglion
Depression for V ganglion
(in petrous temporal bone)
6. Why were no motor deficits
observed in this patient?
Sensory root
Mesencephalic nucleus of V
(proprioceptive)
V1
Pontine sensory nucleus of V
(fine touch)
V2
V3
Motor nucleus of V
(mm of mastication,etc.)
Motor root
Spinal nucleus of V
(pain, temperature)
Motor fibers
Sensory fibers
SENSORY AND MOTOR ROOTS OF V
Midbrain
ANTERIOR
V1
V2
V ganglion
Motor root of V
V nerve cut & reflected
Sensory root of V
7. What may be the cause(s)
of this condition?
Usually the cause of trigeminal
neuralgia is unknown.
INFECTION OF APEX OF PETROUS TEMPORAL BONE
COMPRESSION OF SENSORY ROOT OF V
BY AN ABERRANT ARTERY
Pathological process
involving cells of the
V ganglion
or spinal nucleus
of V
8. How might this condition
be treated?
Medications can be used to treat
this condition. These drugs
increase the threshold to neural
stimulation.
DECOMPRESSION OF SENSORY ROOT OF V
PERCUTANEOUS RADIOFREQUENCY RHIZOTOMY
OF SENSORY ROOT OF V
Partial rhizotomy of sensory root of V
Trigeminal ganglion
PERCUTANEOUS BALLOON COMPRESSION
OF TRIGEMINAL GANGLION
ADDITIONAL NOTE
It is noteworthy that the patient first consulted her dentist about her problem and that
her physician examined her for possible maxillary sinusitis. Under the mistaken belief
that the pain of trigeminal neuralgia is due to dental disease or sinusitis, patients have
had upper teeth extracted and their maxillary sinuses drained, but with no relief.
MAXILLARY NERVE (V2)
V1
V ganglion
Sensory root of V
Infraorbital n.
Anterior superior alveolar n.
V3
V2
Mucosa of maxillary sinus
Dental and gingival branches
Middle superior alveolar n.
Posterior superior alveolar n.
END OF CASE 2.2
TIME