This document discusses the anatomical considerations for local anesthesia, focusing on the trigeminal nerve, its branches (maxillary, mandibular), and associated structures like the sphenopalatine ganglion. It provides detailed descriptions and diagrams of the nerves that innervate the face and oral cavity, including their branches and sensory/motor functions. Key points covered include the branches and distributions of the maxillary and mandibular nerves, as well as the innervation of the maxillary teeth from structures like the posterior superior alveolar nerve.

1. Anatomical Consideration
for Local Anesthesia
Trigeminal Nerve
Maxillary Nerve
Sphenopalatine Ganglion
Mandibular Nerve
Dr. Hesham El-Hawary
ELHAWARY

2. Trigeminal nerve
 Largest of the cranial
nerves
 It is a mixed nerve,
which is made up of
 Large sensory part
 Smaller motor part
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3. Trigeminal nerve Cont.
 The sensory root arises from sensory cells of the
trigeminal ganglion which fills the trigeminal impression
in the floor of the middle cranial fossa
 The motor root arises from motor cells in the
medulla oblongata
 Its name derives from the fact that it has three major
branches:
 Ophthalmic nerve (V1)
 Maxillary nerve (V2)
 Mandibular nerve (V3)
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4. Trigeminal nerve Cont.
 The ophthalmic and maxillary nerves are purely sensory
 The mandibular nerve has both sensory and motor
functions
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5. ELHAWARY

6. The maxillary nerve
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7. The Maxillary Nerve
 It is the 2nd division of the trigeminal nerve
 It arises from the middle of the gasserian ganglion
 It is intermediate in size between the ophthalmic and
Mandibular divisions
 It is purely sensory in function
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8. The Maxillary Nerve Cont.
 It leaves the middle cranial fossa through foramen
rotandum
 Before it leaves the middle cranial fossa it gives off the
middle meningeal nerve to supply the dura
mater
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9. Branches of Maxillary nerve
1. Middle meningeal nerve
2. Twiges to the
sphenopalatine ganglion
3. Posterior superior
alveolar nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
1. Middle superior
alveolar nerve
2. Anterior superior
alveolar nerve
3. Terminal branches
1. Inferior palpebral
nerve
2. External nasal nerve
3. Superior labial nerve
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10. The Posterior Superior Alveolar Neve
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11. Posterior superior alveolar nerve
 It arises from the maxillary nerve just before it
enter the infraorbital groove
 Generally , posterior superior alveolar nerve is two
in number
 One branch descends on the post. Surface of the
maxilla & gives off several twigs to m.m. of the
cheek
 Other branch enters small foramen on the post.
Surface of the maxilla to run in the post. Sup.
Alveolar canal located in the posterior & lateral
walls of the max. sinus
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12. Posterior superior alveolar
nerve Cont.
 It communicate freely with
the middle & anterior
superior alveolar nerves to
form a superior
dental plexus from
which small twigs enter the
apical foramina of the
maxillary teeth & other
twigs supply the overlying
buccal mucoperiosteum
ELHAWARY

13. Posterior superior alveolar
nerve Cont.
 Specifically posterior
superior alveolar nerve
supplies
 The Pulp
 The Investing structures
 The buccal
mucoperiosteum
of Upper Molars except
MB root of 1st molar(6)
ELHAWARY

14. The Zygomatic Nerve
ELHAWARY

15. The Zygomatic Nerve
 Arises from the maxillary nerve as it enters the orbital
cavity
 Divides into two branches:
 Zygomatico-Tempopral
 Zygomatico-Facial
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16. Infra-Orbital Nerve
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17. The Infra-Orbital Nerve
Infra-
 The maxillary nerve enters the inferior orbital fissure to
pass into the orbital cavity
 It turns slightly laterally in the infra-orbital groove and
continues forward in the orbital canal
 In the middle of the course in the canal it gives off the
middle superior alveolar nerve
 Just before the exit of the maxillary nerve from the
infra-orbital foramen and still in the infra-orbital canal
it gives off the anterior superior alveolar nerve
 As it leaves the infra-orbital foramen it gives off the
terminal branches
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18. Middle superior alveolar nerve
 Approximately in the middle of the infraorbital canal it
gives off the middle superior alveolar nerve
 It runs downward and forwards in a canal in the lateral
wall of the maxillary sinus to form part of the superior
dental plexus
 It Supplies
 Pulp
 Investing structures
 buccal mucoperiosteum
of Premolars & MB root of 1st molar(6)
ELHAWARY

19. Anterior superior alveolar nerve
 Just before the exit of the maxillary nerve from the
infraorbital foramen, and while still in infraorbital canal
 It gives off the anterior superior alveolar nerve which
runs in a canal in the anterior wall of the maxillary sinus
to form part of the superior dental plexus
 It supplies
 Pulp
 Investing structures
 labial mucoperiosteum
of anterior teeth(1,2,3).
ELHAWARY

20. Terminal branches of the maxillary
nerve
 As the maxillary nerve leaves the infraorbital
foramen, it gives off its three terminal branches,
which are:
 Inferior palpebral nerve
 External nasal nerve
 Superior labial nerve
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21. The Sphenopalatine
Ganglion
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22. Sphenopalatine ganglion
 Nature: parasympathetic ganglion
 Site: pterygopalatine fossa hanges from the maxillary
nerve
 Roots:
 Sensory root: twigs from the maxillary nerve to the
sphenopalatine ganglion
 Sympathetic root: deep petrosal nerve
 Parasympathetic root: great superficial petrosal
nerve of the 7th cranial nerve (Vidian nerve of facial
nerve)
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23. Sphenopalatine ganglion Cont.
 Branches:
 Orbital nerve
 Nasal nerve
 Palatine nerve
 Pharyngeal nerve
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24. Palatine Branches
 Palatine Branches Divides into:
 Greater (anterior) palatine nerve
 Lesser (posterior) palatine nerve
ELHAWARY

25. Palatine Branches Cont.
 The greater (anterior) palatine nerve
 Emerges from greater (anterior) palatine foramen in the
horizontal part of the palatine bone medial to the upper
third molar
 Supplies palatal mucoperiosteum of maxillary molars &
premolars
ELHAWARY

26. Palatine Branches Cont.
 The lesser ( posterior ) palatine nerve
 Emerges from Lesser (Posterior) palatine foramen in the
horizontal part of the palatine bone medial to the upper
third molar
 supplies uvula, soft palate & posterior part of the hard palate
ELHAWARY

27. Nasal Branches
 Nasal Branches Divides into:
 Long sphenopalatine nerve (nasopalatine nerve)
 Short sphenopalatine nerve
ELHAWARY

28. Nasal Branches Cont.
 The Long sphenopalatine nerve
(nasopalatine nerve)
 Emerges from the incisive foramen in the anterior
part of the median plane of the palate
 supplies palatal mucoperiosteum of maxillary
anterior teeth
ELHAWARY

29. Nasal Branches Cont.
 At the palatal side of the canine region, there is
anastomosis between the nasopalatine
nerve & greater palatine nerve
 The origin of these two nerves (nasopalatine
nerve& greater palatine nerve ) comes
from the sensory root of the sphenopalatine
gangalion (twigs from the maxillary nerve)
ELHAWARY

30. Nerve supply to the maxillary teeth
 From the buccal aspect:
 Posterior superior alveolar nerve
It supplies the pulp, investing structures (periodontium,
periosteum and the alveolar bone) and the buccal
mucoperiosteum of the maxillary third, second and the first
molars except the mesiobuccal root of the first molar
 Middle superior alveolar nerve
It supplies the pulp, investing structure and the buccal
mucoperiosteum of the mesiobuccal root of the first molar,
and the maxillary premolars
 Anterior superior alveolar nerve
It supplies the pulp, investing structures and the labial
mucoperiosteum of the anterior teeth
ELHAWARY

31. Nerve supply to the maxillary teeth
Cont.
 From the palatal aspect:
 The greater (anterior) palatine nerve
It supplies the palatal mucoperiosteum opposite to
the maxillary molars, premolars and canine
 The nasopalatine nerve
It supplies the palatal mucoperiosteum opposite to
the anterior region (including the canine)
ELHAWARY

32. Nerve supply of Maxillary teeth
Pulp , Investing structures & Labial (buccal)
mucoperiosteum
Anterior teeth Anterior superior alveolar nerve
(1,2,3)
Premolars (4,5) &
MB root of 1st Middle superior alveolar nerve
molar(6)
Molars except
MB root of 1st Posterior superior alveolar nerve
molar(6)
ELHAWARY

33. Nerve supply of Maxillary teeth
Cont.
Palatal mucoperiosteum
Anterior
Nasopalatine nerve
teeth (1,2,3)
Premolars
(4,5)
Greater ( Anterior) palatine nerve
&
Molars (678)
ELHAWARY

34. The accessory innervation of the
teeth
 The upper anterior teeth cross innervation may take
place i.e. branch from the anterior superior nerve of the
other side for the pulp, investing structures and labial
mucoperiostieum
 The palatal mucoperiostieum opposite to the uppar
canine take innervation mainly from the nasopalatine
nerve but sometimes it is supplied by interlacing fibers
between the nasopalatine and the greater palatine nerve.
ELHAWARY

35. The Mandibular Nerve
ELHAWARY

36.  It is the 3rd division of the trigeminal nerve
 It is the largest branch of the trigeminal ganglion
 It has undivided trunk & then divides into
anterior & posterior division
 The anterior division is smaller than the posterior
division & mainly motor while the posterior
division is mainly sensory ( mixed nerve)
ELHAWARY

37.  It leaves the middle cranial fossa through
foramen Ovale
 After it leaves the middle cranial fossa it gives
off the nervous spinosum nerve that enter the
middle cranial fossa again through foramen
spinosum to supply the dura mater
 Also it gives the nerve to medial pterygoid
muscle which passes through the otic ganglion
to supply the tensor tempani & palatini muscles
 Both divisions pass medial to the lateral
pterygoid muscle and then branch
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38. Branches of Mandibular Nerve
1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
1. N. to Temporalis msc.
2. N. to Massetter msc.
3. N. to Lateral Pterygoid msc.
4. Long Buccal N.
5. Posterior Division
1. Auriculo-temporal N.
2. Lingual Nerve
3. Inferior Alveolar N.
ELHAWARY

39. Sensory braches of Mandibular
nerve
1. Nervous spinosum nerve (trunk)
2. Long buccal nerve ( Ant. division)
3. Auriculotemporal nerve
4. Lingual nerve ( post. division)
5. Inferior alveolar nerve
 Incisive nerve
 Mental nerve
ELHAWARY

40. Motor braches of Mandibular
nerve
1. Nerve to medial pterygoid muscle
2. Nerve to tensor palatini muscle
3. Nerve to tensor tympani muscle
4. Nerve to lateral pterygoid muscle
5. Nerve to masseter muscle
6. Nerve to temporalis muscle
7. Nerve to mylohyoid muscle
8. Nerve to anterior belly of digastric muscle
ELHAWARY

41. The Auriculo-Temporal nerve
ELHAWARY

42.  It arises by a medial & a lateral root that unite
below the foramen spinosum
 The united nerve passes deep to the lateral
pterygoid muscle
 It gives off :
 Parotid branch
 Articular branch
 Auricular branch
 Temporal branch
 Terminal branch
ELHAWARY

43. The Long Buccal Nerve
ELHAWARY

44. Long Buccal Nerve
 Purely sensory nerve
 Passes between two heads of the lateral
pterygoid muscles
 It emerges beneath the anterior border of the
masseter muscle
 It crosses the anterior border of the ramus at
the level of the occlusal plane of the lower 7 & 8
ELHAWARY

45. Long Buccal Nerve Cont.
It sends fibers to:
 M.M. of the cheek
Except the
posterosuperior area which
receive sensory fibers from
posterior superior alveolar
nerve
 Skin of the cheek
 M.M. of the lower buccal vestibule
 Buccal mucoperiosteum of the lower molars
(6,7,&8)
,&8 ELHAWARY

46. The Lingual Nerve
ELHAWARY

47.  Purely sensory nerve
 Passes between the medial pterygoid muscle and
the ramus of the mandible in the
pterygomandibular space
 In the pterygomandibular space, it lies parallel to
the inferior alveolar nerve, but anterior and
medial (lingual) to it
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48.  Then , it passes below the mandibular
attachment of the superior constrictor muscle
of the pharynx to reach the side of the base of
the tongue a short distance below & behind the
lower third molar (8)
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49. It supplies:
 M.M. of the ant. 2/3 of the tongue
 M.M. of the floor of the mouth
 M.M. of the lateral lingual vestibule
 Lingual mucoperiosteum of the all lower teeth
(1, 2, 3, 4, 5, 6, 7, & 8)
ELHAWARY

50. The Inferior Alveolar Nerve
ELHAWARY

51. The Posterior Division
1. N. To Mylohyoid
msc.
2. Inferior alveolar
nerve
3. Terminal Branches
1. Mental Nerve
2. Incisive Nerve
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52. The Inferior Alveolar nerve
 Mixed nerve (Sensory & Motor)
 Passes in the pterygomandibular space
 Before it enters the mandibular foramen, it gives
off the mylohyoid nerve, which contains
sensory & motor fibers
ELHAWARY

53. The Inferior Alveolar Nerve Cont.
 Mylohyoid nerve
 Motor Fibers supply the
 Mylohyoid muscle
 Anterior belly of digastric muscles
 Sensory fibers supply the
 Skin of the anterior & inferior surfaces of the mental
protuberance
ELHAWARY

54. The Inferior Alveolar Nerve Cont.
 Within the mandible , the inferior alveolar nerve
descends in the inferior alveolar canal
 In the region of the mental foramen, it divides
into two terminal branches
 The mental nerve
 The Incisive nerve
ELHAWARY

55. The Inferior Alveolar Nerve Cont.
Mental nerve
 leaves the mandible through the mental foramen
 It supply:
 Skin of the chin
 Skin of the lower lip
 M.M. of the lower lip
ELHAWARY

56. The Inferior Alveolar Nerve Cont.
Incisive nerve
 Supplies
 pulp & investing structures of the lower anterior
teeth (1, 2,& 3)
Main trunk of the inferior alveolar nerve
which lies in the mandibular canal
 supplies
 Pulp & investing structures of the lower premolar
(4, & 5) & molars teeth (6, 7,& 8)
ELHAWARY

57. The Inferior Alveolar Nerve Cont.
 Inferior alveolar nerve gives branches to form
the inferior dental plexus above the main trunk
of the nerve,
 It supplies
 The investing structures of the corresponding teeth
 In the premolar , canine & anterior area it supply
labial or buccal mucoperiosteum of the
corresponding teeth
ELHAWARY

58. Nerve supply to the mandibular teeth
 Inferior alveolar nerve
 It is a branch from the posterior division of the mandibular nerve
 It supplies the pulp and the investing structures of the
 Mandibular molars
 Premolars
 Anterior teeth (through its terminal branch; the incisive nerve)
 The lingual nerve
 It is a branch from the posterior division of the Mandibular nerve
 It supplies the lingual mucoperiosteum of all the lower teeth, anterior two
thirds of the tongue and the floor of the mouth.
 The long buccal nerve
 It is a branch from the anterior division of the Mandibular nerve.
 It supplies the buccal mucoperiosteum opposite to the lower molars.
ELHAWARY

59. Nerve supply to the mandibular
teeth
Pulp , Investing structures
Anterior teeth
Incisive nerve
(1,2,3)
Premolars (4,5)
& Inferior alveolar nerve
Molars (678)
ELHAWARY

60. Nerve supply to the mandibular
teeth Cont.
Labial (buccal) mucoperiosteum
 Inferior Dental Plexus/mental nerve
Anterior teeth  Cutaneous coli nerve
(1,2,3) ( branch of cervical plexus C2 & c3 )
& gives additional sensory supply for
Premolars (45) premolars ( 4 , 5 ) in about 20 % of
the pt.
Molars (678) Long buccal nerve
ELHAWARY

61. Nerve supply to the mandibular
teeth Cont.
Lingual mucoperiosteum
Anterior teeth
(1,2,3) Premolars Lingual nerve
(4,5) & Molars (678)
ELHAWARY

62. The accessory innervation of teeth
 The lower anterior teeth cross innervations may take
place i.e. branch from the incisive nerve of the other side
for the pulp, investing structures and the labial
mucoperiostieum
 The lower premolar may receive additional nerve
supply from the cutaneous coli nerve (branch from the
cervical plexus of nerves) for their labial
mucoperiostieum
 The lower molars may receive additional nerve supply
from the nerve to mylohyoid for the pulp and investing
structures
ELHAWARY

63. THANK YOU
www.elhawarydentalclinic.com
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