ANATOMY OF HEAD AND NECK NERVE SUPPLY AND LYMPHATIC SUPPLY

MADE BY-AMIT BHARGAVA MDS PROSTHODONTICS (1ST YR)

CONTENTS

NERVOUS SYSTEM
Functions of nervous tissue Classification of nervous systems Anatomical course of cranial nerve LYMPHATIC DRAINAGE Structure Anatomical distribution Site specific drainage Clinical correlations

INTRODUCTION TO NERVOUS SYSTEM

The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions and transmit signals between different parts of its body

FUNCTIONS OF NERVOUS TISSUE::

Sense stimuli in both internal and external environment. Stimuli are analysed & integrated to provide co-ordinated responses Sensory neurons transmit impulses from sense organs to CNS Connector neurons supply connection between sensory and motor neurons. Efferent(somatic) neurons transmit impulses from CNS to a muscle. Efferent(autonomic) neurons transmit impulses to a involuntary muscle or gland.

ALL THE FUNCIONS ARE ACHIEVED BY THREE NERVOUS SYSTEMS OF THE BODY:
1. Central nervous system 2. Peripheral nervous system 3. Autonomic nervous system

CENTRAL NERVOUS SYSTEM

Central nervous system composed of brain and spinal cord Has 4 parts: Spinal cord Rhombencephalon ( medulla, pons, cerebellum) Mesencephalon (midbrain) Prosencephalon (forebrain)
12 PAIRS OF CRANIAL NERVES 31 PAIRS OF SPINAL NERVES

PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system consists of the nerves and outside of the brain and spinal cord. function - connect the central nervous system to the limbs and organs.

AUTONOMIC NERVOUS SYSTEM

Consists of sensory and motor neurons that run in between the central nervous system and the internal organs.

2 divisions::
1. Sympathetic 2. parasympathetic

LIST OF CRANIAL NERVES

I II Olfactory nerve Optic nerve Sensory Sensory

III
IV V VI

Occulomotor nerve
Trochlear nerve Trigeminal nerve Abducent nerve Opth.-Sensory

Motor
Motor Max.-Sensory Motor Mand.-Mixed

VII
IX X XI XII

Facial nerve
Glossopharyngeal nerve Vagus nerve Spinal accessory nerve Hypoglossal Nerve

Mixed
Sensory Mixed Mixed Motor Motor

VIII Auditory nerve

OLFACTORY NERVE

OLFACTORY NERVE

Sensory in nature. Originates in upper nasal concha and superior part of nasal septum. Ends in medial surface of cerebral hemisphere & temporal lobe.

OLFACTORY NERVE

COURSE
Dissolution of inhaled

aromatic molecules in the

mucous lining olfactory epithelial cells and stimulation of its

chemoreceptors.
Exaggeration of the action potential by olfactory receptor cells Pass through cribriform plate of ethmoid bone to synapse in secondary sensory neurons in olfactory bulb Amygdala

OLFACTORY NERVE

APPLIED ANATOMY
Smell is responsible for finer appreciation of taste. LOSS OF SMELL OR ANOSMIA: CAUSES
1. HEAD INJURIES: Sudden shift of cerebral hemisphere results in avulsion of olfactory bulb from brain. 2. FRACTURE OF CRIBRIFORM PLATE: May lead to damage to olfactory nerve and CSF rhinorrhoea. 3. TUMOURS: Tumours of the frontal lobe or those arising near the pitutary gland may cause pressure symptoms on olfactory tract. 4. CHRONIC TUBERCULOUS MENINGITIS

ROLE IN PROSTHODONTICS
1.Cobaltchromiumnickel damages nasal cells due to complex of carnosine with metal 2. methyl methacrylate-methacrylic acid.

N Torbica, S Krstev World at work: Dental laboratory technicians.Occup Environ Med2006;63:145-148

OPTIC NERVE

OPTIC NERVE

Sensory nerve Not a peripheral nerve. Extension of the white matter of brain

Responsible for vision

The optic nerve is a continuation of the axons of the ganglion cells in the retina.

OPTIC NERVE

COURSE
Begins the back of the eye Joins optic chiasma in cranial

cavity.
Extends to lateral geniculate nucleus in thalamus forming optic tract. Ends in visual cortex area in occiptal lobe

APPLIED ANATOMY OF OPTIC TRACT

A) B)

LESION OF OPTIC NERVE:

Total blindness of the corresponding eye. Loss of pupillary light reflex on the affected side and consensual reflex on the sound side.

WHEN A TUMUOR AFFECTS THE BASE OF FRONTAL LOBE , IT MAY PRESS UPON OPTIC NERVE:
Optic atrophy on the affected side, due to pressure.

ARGYLL-ROBERTSON PUPIL specific sign of neurosyphilis.

- Loss of light reflex but the near reflex is retained.

 eye prosthesis - to treat anopthalmous detailed anatomy should be kept in mind. Enucleation ,Evisceration

ROLE IN PROSTHODONTICS

Dr. Kalavathi S.D Restoring Ocular Esthetics Using Ocular Prosthesis Journal of Dental Sciences & Research 1:2: Pages 39-44

OCULOMOTOR NERVE

OCCULOMOTOR NERVE Motor in nature

Supplies all the extra ocular muscles,

except superior oblique and lateral rectus. Supplies sphincter pupillae and cilliaris muscle

OCCULOMOTOR NERVE

DEEP ORIGIN (NUCLEAR ORIGIN)

Ventro medial part of the periaqueductal central grey

matter of the midbrain

OCCULOMOTOR NERVE

COURSE AND RELATIONS

From the superficial origin, piamater (passes in between,Post. & sup.
Cerebellar arteries Pierces arachnoid Mater)

duramater cavernous sinus superior orbital fissure within tendinous ring.

OCCULOMOTOR NERVE

APPLIED ANATOMY:
COMPLETE DIVISION OF OCCULOMOTOR NERVE ON ONE SIDE

a) Ptosis or drooping of the upper eyelid- paralysis of leavator palpebrae superioris b) External strabismus(squint)- unopposed action of lateral rectus c) Dilated or fixed pupil d) Loss of accommodation e) Apparent protrusion of eyeball- flaccid paralysis of ocular muscles. f) Diplopia- where false image is higher than true image.

TROCHLEAR NERVE

TROCHLEAR NERVE

Motor in nature Nerve with the longest

intracranial course.
Supplies -superior oblique muscle.

TROCHLEAR NERVE

DEEP ORIGIN:

Periaqueductal grey

mater of the midbrain

at level of inf. colliculus Lies at level of ventro medial nucleus

of 3rd nerve.
.

TROCHLEAR NERVE

COURSE

trochlear nucleus, duramater, lateral wall of cavernous sinus.

Superior orbital fissure

outside tendinous ring.

TROCHLEAR NERVE

APPLIED ANATOMY
IF TROCHLEAR NERVE IS INJURED

Patient is unable to turn his eye downward and laterally. NO difficulty in looking above horizontal plane. On attempting to look down, double vision is seen. To avoid, patient tilts his head forwards towards the sound side.

TRIGEMINAL NERVE

TRIGEMINAL NERVE
fifth cranial nerve mixed in nature It is the largest of the cranial nerves Nuclei 4 nuclei 1 motor and 3 sensory

TRIGEMINAL NERVE

GASSERION GANGLION
Also known as semilunar ganglion Developed from neural crest. Crescent shaped. Located in meckels cavity. Forms:
Central processes Peripheral processes

TRIGEMINAL CAVE

TRIGEMINAL NERVE

SENSORY ROOT OF TRIGEMINAL NERVE Fibres arise from the semilunar ganglion. Enter brainstem through side of pons.

TRIGEMINAL NERVE

SENSORY ROOT OF TRIGEMINAL NERVE Fibres arise from the semilunar ganglion. Enter brainstem through side of pons.
CENTRAL BRANCHES
(SENSORY ROOTS OF NERVE)

ASCENDING FIBRES

DESCENDING FIBRES

TRIGEMINAL NERVE

SENSORY ROOT OF TRIGEMINAL NERVE Fibres arise from the semilunar ganglion. Enter brainstem through side of pons.
CENTRAL BRANCHES
(SENSORY ROOTS OF NERVE)

ASCENDING FIBRES

DESCENDING FIBRES

Terminate in UPPER sensory nucleus In pons lateral to motor nucleus.

DORSAL TRIGEMINO-THALAMIC TRACT

CONVEY:: Light touch Tactile discrimination Sense of position Passive movement

TRIGEMINAL NERVE

SENSORY ROOT OF TRIGEMINAL NERVE Fibres arise from the semilunar ganglion. Enter brainstem through side of pons.
CENTRAL BRANCHES
(SENSORY ROOTS OF NERVE)

ASCENDING FIBRES

DESCENDING FIBRES

Terminate in UPPER sensory nucleus In pons lateral to motor nucleus. .

CONVEY:: Light touch Tactile discrimination Sense of position Passive movement

Terminate in SPINAL nucleus extending Caudally from upper sensory nucleus to 2nd cervical segment.
CONVEY:: Pain Temperature

TRIGEMINAL NERVE PERIPHERAL BRANCHES

OPTHALMIC nerve

MAXILLARY nerve

MANDIBULAR nerve

OPTHALMIC DIVISION:
Sensory in nature.

TRIGEMINAL NERVE

Route:
Leaves the anterior medial part of the ganglion and passes forward in the lateral part of cavernous sinus.

Fibres are afferent to:

Scalp Skin of forehead Upper eyelid lining the frontal sinus Conjunctiva of eyeball Lacrimal gland Skin of lateral angle of the eye sclera of eyeball Lining of ethmoid cells

TRIGEMINAL NERVE

SUBDIVISIONS
LACRIMAL NERVE FRONTAL NERVE NASOCILLIARY NERVE

TRIGEMINAL NERVE

LACRIMAL NERVE::
Smallest of the three branches. Passes into orbit at lateral angle of

superior orbital fissure.

Courses anterolaterally to reach lacrimal gland. SUPPLIES Lacrimal Gland &Adjacent Conjunctiva.

TRIGEMINAL NERVE

FRONTAL NERVE: (LARGEST OF THREE)

In middle of orbit, nerve divides into:

SUPRA ORBITAL NERVE: Largest branch Leaves orbit through Supra orbital foramen.
SUPPLIES: Skin of upper eyelid Ant. Scalp region to vertex of skull

SUPRA TROCHLEAR NERVE: Smallest Branch Pierces fascia of upper eyelid.

SUPPLIES:
Skin Of The Upper Eyelid Lower medial portion of forehead

TRIGEMINAL NERVE

NASOCILIARY NERVE::
Enters the orbit through superior orbital fissure. Supply- mucous membrane of the nose - the tip of the nose - the conjunctiva.

TRIGEMINAL NERVE

MAXILLARY DIVISION
SENSORY IN NATURE 2nd division of the trigeminal

nerve.
Tansmits afferent impulses from:
Upper lip

Lower eyelid
Tonsillar region Side of the nose Hard and soft palate

Lining of maxillary sinus

Opening of eustachian tubes All maxillary teeth and gingiva Mucous membrane of the nasal cavity

TRIGEMINAL NERVE

COURSE: Intracranial part:: Originates in the middle part of semilunar ganglion Passes forward in lower part of cavernous sinus Exits through foramen rotundum.

TRIGEMINAL NERVE

Extracranial part:: Enters pterygopalatine fossa. Enters inferior orbital fissure to enter orbital cavity. Runs laterally along infra orbital groove. Emerges through infra orbital foramen.

BRANCHES OF MAXILLARY NERVE

BRANCHES IN MIDDLE CRANIAL FOSSA BRANCHES IN PTERYGOPALATINE FOSSA BRANCHES IN INFRAORBITAL GROOVE AND CANAL TERMINAL BRANCHES ON FACE MIDDLE MENINGEAL NERVE

ZYGOMATIC SPHENOPALATINE POSTERIOR SUPERIOR ALVEOLAR MIDDLE SUPERIOR ALVEOLAR ANTERIOR SUPERIOR ALVEOLAR INFERIOR PALPEBRAL LATERAL NASAL SUPERIOR LABIAL

BRANCHES IN MIDDLE CRANIAL FOSSA

MIDDLE MENINGEAL NERVE
Travels with middle meningeal artery. Sensory to the dura matter of anterior half of middle cranial fossa.

TRIGEMINAL NERVE

BRANCHES IN PTERYGOPALATINE FOSSA

A. ZYGOMATIC NERVE:

Emerges in the pterygopalatine fossa. Passes anteriorly and laterally through inferior orbital fissure into orbit.
DIVIDES INTO 2 PARTS::

1.

ZYGOMATICOFACIAL NERVE:

2.

ZYGOMATICOTEMPORAL NERVE:

TRIGEMINAL NERVE

B. PTERYGOPALATINE {SPHENOPALATINE} NERVES:

2 short nerve trunks that unite at pterygopalatine ganglion.

Most of the fibres pass through the ganglion without synapse.

BRANCHES:
ORBITAL NASAL -POSTERIOR SUPERIOR LATERAL NASAL
-MEDIAL OR SEPTAL BANCH

PALATINE - GREATER OR ANTERIOR PALATINE

- MIDDLE PALATINE BRANCH
-POSTERIOR PALATINE BRANCH

TRIGEMINAL NERVE

C. POSTERIOR SUPERIOR ALVEOLAR NERVES

Leave main branch before it enters inferior orbital fissure. Pass downward over posterior surface of maxilla. Enter post. superior alveolar canal along with internal maxillary artery. Supplies-mucous membrane of sinus ,maxillary teeth and its gingivae.

TRIGEMINAL NERVE
BRANCHES IN INFRAORBITAL GROOVE AND CANAL::

1. MIDDLE SUPERIOR ALVEOLAR NERVE

Leaves in posterior part of floor of

Infraorbital canal. Passes downward and anterior over the anterolateral wall of maxillary sinus. Supplies maxillary bicuspids.

2. ANTERIOR SUPERIOR ALVEOLAR NERVE Descends from main trunk to emerge in infraorbital foramen.

Passes through fine canals in maxilla

Supplies: Incisors and cuspids Anterior Part of maxillary sinus Labial gingiva of incisors and cuspids

TRIGEMINAL NERVE
As the infraorbital nerve is about to emerge from the foramen in front of maxilla it divides into:
3 TERMINAL BRANCHES ON FACE

INFERIOR PALPEBRAL BRANCH

Supply sensory fibres to skin of Lower eyelid and its conjunctiva.

LAT. NAS

LATERAL NASAL BRANCH

Pass to skin of the side of the nose.

SUPERIOR LABIAL BRANCH

Distributed to the skin & mucous membrane of the upper lip.

TRIGEMINAL NERVE
MANDIBULAR DIVISION
Largest division of trigeminal nerve. Formed by SMALL MOTOR ROOT LARGE SENSORY ROOT SENSORY ROOT SUPPLIES:
Dura External ear Parotid gland TMJ articulation Lower teeth and gingiva Scalp over temporal region Ant. 2/3rd of the tongue. skin and mucous membrane of chin, cheek & lower lip. Muscles of mastication. Mylohyoid Anterior belly of digastric

MOTOR ROOT SUPPLIES:

TRIGEMINAL NERVE

COURSE
Motor root is located in middle cranial fossa Sensory root emerges from semilunar ganglion 2 roots pass alongside in cranium. Emerging from foramen ovale,they unite.

1. UNDIVIDED

NERVE:

Nervous spinosus Nerve to internal pterygoid

2. DIVIDED NERVE: Anterior division

Branches to ext. pterygoid, masseter, Temporal, buccal

posterior division
Auriculotemporal ,lingual, inferior alveolar

TRIGEMINAL NERVE

BRANCHES FROM UNDIVIDED NERVE:

A.) NERVOUS SPINOSUS
Arises outside the skull and then passes in the middle cranial fossa to supply dura and mastoid cells.

b.) NERVE TO INTERNAL PTERYGOID A branch passes to innervate internal pterygoid muscle. A sub branch passes for tensor veli palatini and tensor tympani muscles.

TRIGEMINAL NERVE

BRANCHES FROM DIVIDED NERVE: ANTERIOR DIVISION:

A.) PTERYGOID NERVE:
Enters the medial side of external pterygoid muscle for its motor supply.

B.) MASSETER NERVE: Passes above the external pterygoid to traverse the mandibular notch and enter the deep side of masseter muscle.

TRIGEMINAL NERVE C.) TEMPORAL NERVES:

Passes upwards crosses the infratemporal crest of sphenoid bone, enters the anterior deep part of the temporalis muscle.

TRIGEMINAL NERVE

D.) BUCCAL NERVE:

Passes downwards, anteriorly and laterally between the two heads of external pterygoid muscle. At the level of occlusal plane It ramifiesMotor innervation to cheek Sensory innervation to cheek

Sensory fibres to retromolar pad

Sensory fibres to buccal gingivae

TRIGEMINAL NERVE

POSTERIOR DIVISION
A. AURICULOTEMPORAL NERVE:
Arises by a medial and a lateral root. COURSE: Passes posteriorly,Deep to external pterygoid muscle. Between sphenomandibular ligament & neck of condyle.

Traverses upper deep part of parotid

Crosses posterior root of zygomatic arch

TRIGEMINAL NERVE

BRANCHES OF AURICULOTEMPORAL NERVE

PAROTID BRANCHES

ARTICULAR BRANCHES
AURICULAR BRANCHES MEATAL BRANCHES TERMINAL BRANCHES:: Supply scalp over the temporal region.

TRIGEMINAL NERVE

B. LINGUAL NERVE
Passes medially to external pterygoid muscle and descends, Lies between internal pterygoid muscle & ramus of mandible in pterygomandibular space. In pterygomandibular space,Lingual nerve lies parallel to inferior Alveolar

Nerve but lingual & anterior to it.

C. INFERIOR ALVEOLAR NERVE:

Largest branch of the posterior division. Passes downwards,give branch to mylohyoid

Enters mandibular foramen,

Distributed throughout mandible.

Reaches mental foramen, 2 terminal branches Mental nerve Incisive nerve

MYLOHYOID NERVE:
Branch of inferior alveolar nerve

Both sensory & motor fibres.

Continues downward & forward in mylohyoid groove. Motor fibres Supply: Mylohyoid muscle Anterior Belly of digastric

APPLIED ANATOMY
TRIGEMINAL NEURALGIA
It is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve Tic Doloureaux CLINICAL FEATURES Pain is unilateral (rarely bilateral). Duration of pain - few seconds to 1-2 minutes. Pain may occur several times a day;. patients typically experience no pain between episodes. Trigger zone

 CAUSE 1. vascular compression superior cerebral artery 2. multiple sclerosis 3. Aneurysm 4. tumor 5. arachnoid cyst in the cerebellopontine angle 6. by a traumatic event such as a car accident or even a tongue piercing

Treatment
Medical Surgical

Medical Treatment
Carbamazepine Should be the initial Rx of choice for classical Trigeminal Neuralgia If get no or only partial response to carbamazepine, add or substitute another pharmacologic agent: Baclofen : 10 m- 80 mg daily Dilantin Lamictal

Surgical Treatment
Both percutaneous & open techniques
Glycerol injection Radio Rhizotomy Partial Rhizotomy Ballon Compression Gamma knife Microvascular decompression

ROLE IN PROSTHODONTICS
Trigger zone Development of a chronic pain state caused by injury to peripheral branches of the trigeminal nerve after surgical and nonsurgical procedures.

Delcanho RE Neuropathic implications of prosthodontic treatment.J Prosthet Dent. 1995 Feb;73(2):146-52

ABDUCENT NERVE

ABDUCENT NERVE Motor in nature Supplies lateral rectus muscle Lateral rectus muscle is responsible

for visual tracking & fixing of object.

Origin:
Nucleus situated beneath floor of fourth ventricle in dorsal part of pons.

ABDUCENT NERVE

Course
From pons, Pierces dura mater

Inferior petrosal sinus

cavernous sinus

Sup.Orbital fissure

with in tendinous ring supply lateral rectus

ABDUCENT NERVE

APPLIED ANATOMY:
Involvement produces paralysis of lateral rectus,resulting in medial or convergent squint or diplopia. unable to look laterally

FACIAL NERVE

FACIAL NERVE
Mixed nerve Three nuclei -1 motor and 2 sensory Motor nucleus: it is present in the pons. sensory a) the superior salivatory nucleus: b)The nucleus of the tractus solitarius:

COURSE

Pons

COURSE

Stylomastoid canal and foramen

Posteromedial surface of Parotid gland

Behind the neck of mandible It divides into its Five terminal branches

BRANCHES
A.WITHIN THE FACIAL CANAL1.Greater petrosal nerve 2.Nerve to stapedius 3. Chorda tympani B.AT ITS EXIT FROM STYLOMASTOID FORAMEN 1.Posterior auricular 2.Digastric 3.Stylohyoid C.Terminal branches within parotid gland 1.Temporal 2.Zygomatic 3. Buccal 4.Mandibular 5.Cervical

A.WITHIN THE FACIAL CANAL

1.GREATER PETROSAL NERVE supply mucous glands of nose, palate & lacrimal glands

A.WITHIN THE FACIAL CANAL

2.NERVE TO STAPEDIUS small motor nerve for stapedius muscle which is attached to the stapes the innermost of the three auditory ossciles.

A.WITHIN THE FACIAL CANAL

3. CHORDA TYMPANI The taste fibers follow the lingual nerve into the Substance of the tongue & are distributed to the taste buds.

B.AT ITS EXIT FROM STYLOMASTOID FORAMEN

POSTERIOR AURICULAR NERVE Turns backwards & upwards between the mastoid process & the auricle and supplies the posterior auricular & the occipital muscles

C.TERMINAL BRANCHES WITHIN PAROTID GLAND

1.TEMPORAL -the auricular muscles, Frontalis,Orbicularis oculi, Corrugator 2.ZYGOMATIC-Orbicularis oculi 3. BUCCAL-Procerus,zygomaticus, Quadratus labii superioris, muscles of the nose,buccinator and orbicularis oris 4.MANDIBULAR-muscles of the lower lip and chin 5.CERVICAL-Platysma.

APPLIED ANATOMY
GENICULATE GANGLION Ramsay hunt syndromeHerpes zoster infection of ganglion Signs Vesicles on ear, oral mucosa, tonsil, posterior one third of tongue Loss of taste Pain Decrease salivation Palatal paralysis

BELLS PALSY
Definition :- idopathic paralysis of facial nerve of sudden onset. Incidence :- 15 40 cases per one lac cases. Sex predilection :- F > M . It is 3.3 times more common in pregnant women ( especially in third trimester ) Age :- can occur at any age. More common in middle aged people. Side involvement :- equally involved left & right sides. Usually unilateral but in 1% cases bilateral involvement can be seen.

 Causes: Congenital Trauma Iatrogenic Idiopathic Infection Toxic Neurologic Neoplastic

CLINICAL FEATURES Facial asymmetry Drooping of corner of mouth Inability to close eye Uncontrolled tearing Facial muscle atrophy Eyebrow droop Loss of forehead and nasolabial folds Pain near mastoid process Sensory loss Others- Hyperacusis,Dysgeusia

 Congenital:i) Moebius Syndrome :Due to congenital nuclear aplasia. ii) MelkerssonRosenthal Syndrome :Cheilitis Granulomatosa + Facial Palsy + Scrotal Tongue

Neoplastic :-

i) Facial Nerve Tumours Schwannoma, Neurofibroma ii) Parotid Tumors

iii) Temporal bone or External Auditory Canal Tumours

Infectious :i) Mastoiditis

ii) Viral causes :- Herpes zoster (Ramsay Hunt Syndrome ), mumps, infectious mononucleosis iii) Bacterial causes :- Diphtheria, Tuberculosis

TREATMENT
Eighty percent of patients with Bell's palsy have normal or nearnormal recovery without any treatment.

DRUG THERAPY-CORTICOSTEROIDSPrednisone 80 mg *5days

-ACYCLOVIR -2000 mg/day*7 days SURGICAL NERVE GRAFTING ( Hypoglossal nerve has been a very effective autogenous graft)

ROLE IN PROSTHODONTICS
Complete denture fabrication in patient with bells palsy

primary and final impressions excessive material is incorporated on the affected side The polished surface of denture base was contoured by functions of the tongue and action and tonus of affected and unaffected lips and cheek Occlusal wax Rims - Midline placed in the middle of the oral cavity rather than the facial midline Non anatomic posterior teeth are used to establish the centric occlusion Some improvement of the appearance can be achieved by: 1. Placing the mesio-incisal point in the middle of the mouth rather than the middle of the face 2. keep the cant of the occlusal plane on the affected side a little low for incisal show 3. Buccal sulcus support - Placing buccal support on the affected side to reduce the facial droop.This will also help reduce the accumulation of food in the affected buccal vestibule
Suresh S Prosthodontic management of complete edentulous patients with neuromuscular disorders Case reports. Journal of Advanced Dental Research Vol II : Issue I: January, 2011

VESTIBULOCOCHLEAR NERVE

VESTIBULOCOCHLEAR NERVE
This nerve is responsible for transmitting sound and equilibrium (balance) information from the inner ear to the brain. NUCLEUS -2 cochlear nucleii in inferior cereberal peduncle -4 vestibular nucleii in pons and medulla

COURSE
The cochlear nerve travels away from the cochlea of the inner ear where it starts as the spiral ganglia.Connects organ of corti to cochlear nuclei The vestibular nerve travels from the vestibular system of the inner ear. The vestibular ganglion houses the cell bodies of the bipolar neurons

APPLIED ANATOMY
Damage vestibulocochlear nerve may cause the following symptoms hearing loss, vertigo , false sense of motion , loss of equilibrium (in dark places) , nystagmus , motion sickness , tinnitus.

GLOSSOPHARYNGEAL
Mixed nerve Motor fibres stylopharyngeus Sensory fibres pharynx, tonsils, posterior part of tongue,parotid gland Nuclei - medulla

COURSE
COURSE Medulla Jugular foramen

superior nucleus nucleus

Inferior

pharynx,tonsils,tongue Parotid gland via lesser petrosal nerve

BRANCHES
1.TYMPANIC NERVE 2.CAROTID 3.PHARYNGEAL 4.MUSCULAR 5.TONSILLAR 6.LINGUAL

APPLIED ANATOMY
1.Tested clinically Tickling posterior wall of pharynx Taste sensibility on posterior one third of tongue 2.Isolated lesions- Unknown 3.Neuralgia 4. Involved in swallowing and gag reflex, considered to be as the taste nerve, mainly for the sweet and bitter tastes.

GLOSSOPHARYNGEAL NEURALGIA DEF.-It consists of recurring attacks of severe pain in back of throat near the tonsils and back of tongue due to malfunction of cranial nerve IX. Cause-unknown, -artery that compresses the glossopharyngeal nerve , -tumor in the brain or neck

 Attacks are brief Triggered by chewing,swallowing,coughing or sneezing

Pain begins at back of tongue or back of throat Pain- unilateral,severe and paroxysmal Older age group is affected

CLINICAL FEATURES

ROLE IN PROSTHODONTICS
GAG REFLEX - Nausea manifests itself through an unpleasant feeling that precedes the sensation of vomiting

Lavinia Ardelean, et al .Gag reflex in dental practice etiological aspects. TMJ 2003, vol. 53, no. 3-4

PHYSIOLOGICAL MECHANISMS
Inborn reflex Regresses in first four years of life. It becomes more posterior after the appearance of the first dentition(tonsil pillars) The persistence - orofacial immaturity in forms of dysphagia. The sensor stimuli are detected by three types of receptors - orofacial, digestive, blood flow level.

OROFACIAL RECEPTORS
REAL REFLEX FIELD palatine veil, posterior pharynx ,tonsillar pillars , receptors,tongue papillae that carry the taste buds are rich in nociceptive

DIGESTIVE RECEPTORS
The afferences coming from the digestive tract, conveyed mainly through the vagus nerve, reach the solitary nucleus

BLOOD-FLOW RECEPTORS
Pathological humoral alterations, such as uremia or drug poisoning can act on the bulbar centre of vomiting. The hormonal changes inherent to pregnancy act through the blood flow and may induce nausea.

THE IMPORTANCE OF GAG REFLEX ETIOLOGY IN DENTAL PRACTICE

Clinically, there are several therapeutic acts susceptible to stimulate, directly or indirectly, the areas and reflex paths, a stimulation that is manifested by triggering INBORN OR ACQUIRED, LOCAL OR GENERAL REFLEXES.

INBORN REFLEXES
Any risk of blocking the airways triggers the gag reflex. This depends mainly on two factors: oral breathing hypersalivation

ACQUIRED REFLEXES

GENERAL

LOCAL ORIGIN

Alcoholism Digestive or hepato-biliary disorders Emetic medication.

Olfactory/taste stimuli Mechanical stimuli Acoustic stimuli Visual stimuli Psychic stimuli

MANAGEMENT OF GAG REFLEX

Distraction techniques Relaxation Pharmacological Techniques Local Anesthesia Conscious sedation

Milind Limaye, Naveen HC, Aditi Samant. The gag reflex etiology and management. International Journal of Prosthetic Dentistry.2010:1(1):10-14. 2010 International Journal of Prosthetic Dentistry

PROSTHODONTIC TECHNIQUES
Borkin recommends low-fusing wax as an impression material Webb suggests that distortion of tissue contour due to injection of anesthetic solution can be minimized by adding hyaluronidase (I-3cc) to 2 % lidocaine HCI (1cc).

MODIFICATION OF EDENTULOUS MAXILLARY CUSTOM TRAY TO PREVENT GAGGING

The modified maxillary custom acrylic resin tray to which second layer of autopolymerising tray acrylic has been attached to original custom tray with wax spacer removed aids in removal of excess impression material as it extrudes from the posterior border of the maxillary custom tray before it can elicit a gag reflex in the patient.

 PALATE LESS DENTURES: A cast metal denture base of aluminum or chrome nickel alloy is recommended THE MARBLE TECHNIQUE SYSTEMATIC DESENSITIZATION ERRORLESS LEARNING- The patient is instructed to set aside time to position the denture closer each day and eventually into the mouth in successive approximations

 Training bases - A thin acrylic denture base, without teeth is fabricated and the patient is asked to wear it at home, gradually increasing the length of time the training base is worn

VAGUS
Mixed nerve Nuclei-located in medulla

COURSE Medulla jugular foramen, carotid sheath

VAGUS

neck, chest and abdomen

viscera

BRANCHES IN HEAD AND NECKA.IN JUGULAR FORAMEN1.Meningeal 2.Auricular skin of ear

B.IN NECK 1.Pharyngeal-muscles and

mucous membrane of the pharynx (except the stylopharyngeus) and the muscles of the soft palate, except the Tensor veli palatini 2.Carotid

3.Superior laryngeal External Laryngeal (cricothyroid) Internal laryngeal (mucous membrane of the pharynx and larynx)

4.Right recurrent laryngeal all muscles of larnyx 5.Cardiac

APPLIED ANATOMY
1.Tested clinically- Comparing palatal arches 2.Paralysis Nasal regurgitation-pharyngeal branch Nasal twang in voice - recurrent laryngeal nerve Hoarseness of voice recurrent laryngeal nerve Flattened palatal arch - pharyngeal branch Dysphagia pharyngeal branch

ACCESSORY NERVE
Motor nerve Nucleus nucleus ambiguus Formed by spinal and cranial roots

COURSE OF ACCESSORY NERVE

Jugular foramen Cranial root spinal root

muscle of soft sternocleidomastoid and trapezius palate and pharynx

APPLIED ANATOMY
IT IS TESTED CLINICALLY1.ASKING PT. TO SHRUG HIS SHOULDERS 2.TURN FACE TO OPPOSITE SIDE WRY NECK

HYPOGLOSSAL NERVE
Motor nerve Nucleus- hypoglossal nucleus in medulla

COURSE OF NERVE
hypoglossal nucleus hypoglossal canal

It spirals behind the vagus nerve and passes between the internal carotid artery and internal jugular vein (carotid sheath)
submandibular region to enter the tongue

BRANCHES
1. Meningeal branch 2. Descending ramusOmohyoideus,Sternohyoideus , the Sternothyreoideus, and the inferior belly of the

Omohyod.

3. Thyrohyoid 4. Geniohyoid

APPLIED ANATOMY
Tested clinically- Protrude tongue Lesion of nerve- Paralysis of tongue A.Infranuclear lesions Gradual atrophy In motor neuron disease , syringobulbia

B.Supranuclear lesions Paralysis without wasting Seen in pseudobulbar palsy

LYMPHATIC DRAINAGE OF THE HEAD AND NECK

THE LYMPHATIC SYSTEM

The lymphatic system is a part of the circulatory system, comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectional towards the heart

FUNCTION
To provide an accessory route for the excess plasma to get returned to the blood. Secondly the lymphatic organs play an important part in the immune system

LYMPH
Lymph is the fluid that circulates throughout the lymphatic system. The lymph is formed when the interstitial fluid is collected through lymph capillaries.It is then transported though lymph vessels to lymph nodes before emptying ultimately into the right or the left subclavian vein, where it mixes back with blood.

FUNCTION OF LYMPH
Lymph returns protein and excess interstitial fluid to the circulation. Lymph may pick up bacteria and bring them to lymph nodes where they are destroyed. Metastatic cancer cells can also be transported via lymph. Lymph also transports fats from the digestive system

LYMPH NODE

SURFACES

SUBCAPSULAR SINUS

OUTER CORTEX

INNER MEDULLA

 CLASSIFICATION OF HEAD & NECK LYMPH NODES

Classification of Head & Neck Nodes

WALDEYERS CLASSIFICATION

WALDEYERS INTERNAL RING

Adenoid Lingual Palatine Posterior pharyngeal wall lymphoid aggregate

WALDEYERS EXTERNAL RING

The ring in the head constitues Skull base nodes Occipital nodes Postauricular nodes Parotid nodes and Buccal lymph nodes . The ring in the neck constitutes Superficial Cervical nodes Submandibular nodes Submental and Anterior cervical nodes

SUPERFICIAL LYMPH NODE

Located at junction of head and neck INCLUDES
occipital Post auricular Parotid Buccal Superficial cervical Submental Submandibular Anterior cervical

DEEP LYMPH NODE

located along internal jugular vein within carotid sheath Upper Middle Lower In general lymph flows from superficial to deep and from superior to inferior

INCLUDES

SITE SPECIFIC DRAINAGE IN HEAD & NECK

SUPERFICIAL PAROTID LYMPH NODES

Location-anterior to the tragus superficial or deep to the parotid fascia. Drainage

POSTERIOR AURICULAR LYMPH NODES

Location-superficial to the mastoid attachment of sternocleidomastoid muscle Drainage Strip of Scalp above Auricle Posterior Wall of external auditary meatus(Upper half of Auricle)

OCCIPITAL NODES
Location - the superior angle of the posterior triangle superficial to the upper attachment of trapezius
Drainage - the occipital scalp

SUPERFICIAL CERVICAL LYMPH NODES

Location - along the external jugular superficial to the sternocleidomastoid muscle.
Drainage Floor of the EAM Lobe of the Auricle Skin over Angle of Mandible Lower Parotid region.

SUBMANDIBULAR LYMPH NODES

Location - internal to the investing layer of the deep fascia of the neck in the submandibular triangle

Afferents - facial nodes (nasolabial

and buccal ) , submental & Parotid nodes may drain

SUBMENTAL LYMPH NODES

Location - on the mylohyoid muscle between the anterior bellies of digastric.

Drainage -Mandibular Anterior Alveolar ridge Anterior 1/3rd of floor of the mouth Lower Lip (except lateral thirds)

UPPER DEEP CERVICAL NODES

Located - upper third of the internal jugular vein deep to the sternocleidomastoid muscle . Jugulodigastric node- in triangular region bounded by the posterior belly of digastric , facial vein and IJV. Efferents from these nodes drain to the middle deep cervical nodes or directly to the jugular trunk.

Afferents from the parotid posterior-auricular , occipital , superficial cervical , submandibular , retropharyngeal and prelaryngeal lymph nodes
Drains wide areas of face , oral cavity , tongue , tonsils , nose , nasal cavity , nasopharynx , parotid and submandibular gland and supraglottic larynx .

MIDDLE DEEP CERVICAL NODES

Located around middle third of the internal jugular vein The Juguloomohyoid lymph node lies just on or above the tendon of omohyoid muscle.
Efferents from these nodes drain to the inferior deep cervical nodes or directly to the jugular trunk.

afferents from the upper deep cervical nodes , submental nodes , suprahyoid nodes , prelaryngeal nodes , paratracheal nodes

LOWER DEEP CERVICAL

Location- lower1/3rd of the internal jugular vein

Afferents- middle deep cervical nodes , anterior superficial cervical , spinal accessory nodes and transverse cervical nodes

CLINICAL CONSIDERATIONS

PALPATION OF LYMPH NODES

Use the pads of all four fingertips
Examine both sides of the head simultaneously Applying steady, gentle pressure Evaluated in a systematic fashion

PREAURICULAR NODES
Stand behind the patient Gently tilt the head to the opposite side of node being palpated Roll your finger in front of the ear, against the bone.

POSTAURICULAR NODES
Stand behind the patient Gently tilt the head to the opposite side of node being palpated

Roll your finger behind the auricle , against the mastoid process.

SUBMANDIBULAR NODES
Stand behind the patient Gently tilt the head to the same side of node being palpated Roll your fingers against inner surface of mandible applying pressure against the bone.

SUBMENTAL NODES
Stand behind the patient Gently tilt the head in front . Roll your fingers against inner surface of symphysis applying pressure against the bone.

SUPERFICIAL CERVICAL NODES

Stand behind the patient Palpate using four fingers above the sternocleidomastoid muscle using rolling motion

DEEP CERVICAL NODES

They are located deep to the sternocleidomastoid muscle and are often inaccessible Palpate by standing behind the patient and hooking thumb and fingers around either side of the muscle.

PATHOLOGIES ASSOCIATED WITH LYMPHATIC SYSTEM

DEVELOPMENTAL
CYSTIC HYGROMA CONGENITAL LYMPHEDEMA

NEOPLASTIC

CAVERNOUS HEMANGIOMA GIANT CELL LYMPHOMA LYMPHOEPITHELIOMA LYMPHOENDOTHELIOMA LYMPHANGIOSARCOMA UNDIFFRENTIATED LYMPHOMA HODGKINS DISEASE NON-HODGKINS DISEASE
Lymphangitis Lymphadenitis Lymphoedema Lymphadenopathy

INFLAMMATORY

DEVELOPMENTAL PATHOLOGY
CYSTIC HYGROMA - A cystic hygroma is a congenital multiloculated lymphatic lesion that can arise anywhere, but is classically found in the left posterior triangle of the neck. This is the most common form of lymphangioma

CONGENITAL LYMPHEDEMA - Congenital lymphedema is a blockage of fluid in the developing fetal lymphatic system.

INFLAMMATORY PATHOLOGIES
LYMPHANGITIS - Lymphangitis is an inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel. The most common cause of lymphangitis in humans is Streptococcus pyogenes LYMPHADENITIS is an infection of the lymph nodes.
Causes are Viral -Common upper respiratory infections,Infectious mononucleosis ,cytomegalo virus,Acquired immunodeficiency syndrome,Rubella,Varicella,Measles Bacterial Septicemia , Typhoid fever, Tuberculosis, Syphilis, Plague Protozoal - Toxoplasmosis Fungal - Coccidioidomycosis

 LYMPHOEDEMA - Lymphedema is a
condition characterized by swelling in one or more extremities that results from impaired flow of the lymphatic system. Causes are most commonly filariasis in india, and after breast cancer surgery.

REFERENCES
1.
2. 3. 4. 5.

6.
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