Clinical anatomy of maxillary narvae.

1. APPLIED
ANATOMY OF
MAXILLARY
NERVE
Presented by Anirban Mallik(B.D.S. 3rd year)

2. INTRODUCTION
 It is the nerve of maxillary process, that
differentiates from first pharyngeal arch.
 It is purely sensory; and is intermediate in
size between ophthalmic and mandibular
nerve.

3. ORIGIN
 Sensory root fibers of trigeminal nerve
comprises of the central processes of ganglion
cells located in trigeminal ganglion.
 Sensory root fibers enter the concave portion
of each crescent and the three sensory
divisions of trigeminal nerve exit from the
convexity.
 The 2nd sensory division among these three is
Maxillary Nerve.
 It originates from the middle part of
trigeminal ganglion in middle cranial fossa.

4. Fig 1: Origin and Course of Maxillary nerve

5. COURSE
It gives off meningeal branch in middle cranial fossa
which is sensory.
The nerve runs forwards through lower part of lateral
wall of cavernous sinus.
The lateral wall here fuses with endosteal layer of
dura mater at lateral margin of foramen rotundum.
It has a short course below the root of pterygopalatine
fossa to inferior orbital fissure.

6. As it crosses pterygopalatine fossa, it gives off its
main branches to pterygopalatine ganglion, posterior
superior alveolar nerve and zygomatic branches.
It then angles laterally in a groove on posterior
surface of maxilla, entering the orbit through
inferior orbital fissure.
Within the orbit it occupies the infraorbital groove
and becomes infraorbital nerve which courses
anteriorly into the infraorbital canal.
The maxillary nerve emerges on anterior surface of
face through infraorbital foramen.

7. INNERVATION
Nasal
mucosa,

9. BRANCHES
Maxillary nerve gives off
branches in four regions:
1. Within the cranium
2. In the pterygopalatine
ganglion
3. In the infraorbital canal
4. On the face.

11. Branches Within the Cranium: Middle
Meningeal Nerve:
 Immediately after separating from trigeminal
ganglion, the maxillary nerve gives off a small
branch, middle meningeal nerve.
 It travels with middle meningeal artery. It
provides sensory innervation to the dura
mater of anterior half of middle cranial fossa.

12. Branches in the Pterygopalatine Fossa:
i. Pterygopalatine
nerves
ii. Zygomatic nerves
iii. Posterosuperior
alveolar nerves.

13. Pterygopalatine nerves: Two short nerves,
that suspend the pterygopalatine ganglion.
 They pass through the ganglion into its
branches and also serve as a communication
between pterygopalatine ganglion and
maxillary nerve.
 By way of ganglion, the maxillary nerve has
the four branches carrying sensory,
secretomotor and sympathetic fibers.
1.Orbital branches: Supply periosteum of orbit.
2.Nasal branches: Supply mucous membranes
superior and middle conchae, the lining of

14. posterior ethmoidal sinus and posterior portion of
nasal septum. These convey postganglionic
parasympathetic fibers from pterygopalatine
ganglion to nasal glands.
I. Nasopalatine nerve (long sphenopalatine
nerve)
II. Posterior superior lateral nasal nerves (short
sphenopalatine nerves)
3. Palatine branches:
a. Greater palatine nerves (or anterior
palatine nerves)
b. Lesser palatine nerves (or middle and
posterior palatine nerves).

16.  These branches provide sensory innervation
to hard and soft palate. These branches
also convey postganglionic parasympathetic
fibers from pterygopalatine ganglion to
palatal glands.
4. Pharyngeal branch: It provides sensory
innervation to nasopharynx.

17.  Zygomatic Nerves:
 It provides sensory innervation to skin over
zygomatic region.
 These nerves also convey postganglionic
parasympathetic fibers from pterygopalatine
ganglion to lacrimal nerve and glands.
 It is a terminal branch.
 The zygomatic nerve enters zygomatic bone and
divides into two branches
a. Zygomaticotemporal nerve: It perforates
temporal surface of zygomatic bone, pierces

18. temporalis fascia and supplies skin above
zygomatic arch (skin of side of forehead or the
“hairless” skin of temple).
b. Zygomaticofacial nerve: It perforates the
facial surface of zygomatic bone and supplies
skin over the bone (skin over the prominence
of cheek). It carries secretomotor fibers from
pterygopalatine ganglion for lacrimal gland.

19. Posterosuperior Alveolar Nerves:
 These nerves are two to three in number.
 These descend from the main trunk of the
maxillary nerve in the pterygopalatine fossa just
before the mandibular division enter inferior
alveolar canal.
 They emerge through the pterygomaxillary
fissure.
 One of it’s branch provides sensory
innervation to buccal gingiva in maxillary molar
region and adjacent facial mucosal surfaces.

20.  Other branch enters maxilla (along with a
branch of internal maxillary artery) through
the posterior or posterolateral wall of
maxillary sinus, and provides sensory
innervation to mucous membrane of sinus.
 Continuing downward, this second branch
provides sensory innervation to alveoli,
periodontal ligaments and pulpal tissues of
maxillary molars, with the exception of (25%)
patients of mesiobuccal root of first molar.

21. Branches in the Infraorbital Canal:
In the infraorbital canal, the maxillary division
gives two branches:
1. Middle superior alveolar nerve
2. Anterior superior alveolar nerve
It supplies multiple small branches through orbital
plate of maxilla to roof of maxillary sinus.
1. Middle superior alveolar nerve: It supplies
adjacent mucosa of maxillary sinus; two premolars
and mesiobuccal root of first molar, periodontal
tissues, buccal soft tissue and bone in premolar
region.

22. 2.Anterior superior alveolar nerve: It is
relatively larger branch. Within the anterior wall
of maxillary sinus, provides innervation to
central and lateral incisors and the canines as
well as sensory innervation to periodontal
tissues, buccal bone and buccal gingiva of these
teeth.
 In patients where middle superior alveolar
nerve is absent, the anterior superior alveolar
nerve provides sensory innervation to
premolars and occasionally the mesiobuccal
root of first molar.

23. Branches on the Face:
 Infraorbital nerve emerges on the face through
infraorbital foramen, lies between levator labii
superioris and levator anguli oris, divides into its
terminal branches.
i. Inferior palpebral supply skin of lower eyelid with
sensory innervation to both surfaces of conjunctiva.
ii. External nasal/lateral nasal provides sensory
innervation to skin on lateral aspect of nose

24. iii. Superior labial provides sensory innervation to
skin and mucous membrane of whole of upper
lip (and sometimes also the adjacent gingiva
from midline to second premolar teeth).
 Infraorbital nerve has many communications
with local branches of 7th cranial nerve, i.e.
facial nerve, these are for proprioceptive
supply of nearby facial muscles.

25. APPLIED ANATOMY
 Maxillary nerve has an important role in
Anesthesia.
 Maxillary Anesthesia is of three types-
1.Local Infiltration
2.Field Block
3.Nerve Block

26. Small terminal nerve
endings in the area of
the dental treatment
are flooded with local
anesthetic solution.
Incision is then made
into the same area in
which the local
anesthetic has been
deposited
1.Local Infiltration

27. Local anesthetic is
deposited near the
larger terminal
nerve branches.
Incision is then
made into an area
away from the site
of injection of the
anesthetic.
Maxillary injections
administered above
the apex of the
tooth to be treated
are properly
termed field blocks
2.Field Block

28. Local anesthetic is deposited
close to a main nerve trunk,
usually at a distance from the site
of operative intervention.
Posterior superior alveolar,
inferior alveolar, and nasopalatine
injections are examples of
maxillary nerve blocks.
3.Nerve Block

29. Types of Injections:
Supraperiosteal (infiltration)
Periodontal ligament (PDL, intraligamentary)
Intraseptal injection
Posterior superior alveolar nerve block
Middle superior alveolar nerve block
Anterior superior alveolar nerve block
Greater (anterior) palatine nerve block
Nasopalatine nerve block
Maxillary (second division) nerve block
Anterior middle superior alveolar nerve block
Palatal approach-anterior superior alveolar nerve block

30. Supraperiosteal Injection
 Nerves anesthetized– terminal branch of
dental plexus
 Areas anesthetized
 Entire region innervated by the large
terminal branches of this plexus

31. Posterior superior alveolar nerve
block
 Nerves Anesthetized-
 Posterior superior alveolar and its branches
 Areas Anesthetized-
1) Pulps of the maxillary 3rd , 2nd and 1st molars
2) Buccal periodontium and bone overlying these teeth

32. Anterior superior alveolar(ASA) nerve
block
 Nerves anaesthetized
1. ASA nerve
2. MSA nerve
3. Infraorbital nerve – inferior palpebral
 -- lateral nasal
 -- superior labial
 Areas anaesthetized
1. Pulps of maxillary C.I. through canine on the injected side
2. Pulps of maxillary premolars(72% of patients) & mesiobuccal
root of the molar

33. Middle Superior Alveolar Nerve Block
 Nerves anaesthetized: MSA & terminal
branch
 Areas anaesthetized
1. Pulps of maxillary 1st & 2nd premolar &
mesiobuccal root of 1st molar(28%)
2. Buccal periodontal tissues & bone of
these teeth

34. Greater palatine nerve block
 Nerves anesthetized
 Greater palatine nerve
 Areas anesthetized
 Posterior portion of the hard palate & its
overlying tissues
 Anteriorly as far as the 1st premolar &
medially to the midline

35. Nasopalatine Nerve Block
 Nasopalatine nerve block is an invaluable
technique for palatal pain control.
 In this administration of a minimum volume of
anesthetic solution (maximally, one quarter of
a cartridge), a wide area of palatal soft tissue
anesthesia is achieved, thereby minimizing the
need for multiple palatal injections.

36. Anterior middle superior alveolar
nerve block
 Nerves anesthetized
1. ASA nerve
2. MSA nerve
3. Subdural dental nerve plexus of the ASA & MSA
 Areas anesthetized
1. Pulpal anesthesia of maxillary C.I. canines & premolars
2. Buccal attached gingiva of these same teeth
3. Attached palatal tissues from midline to free gingival
margin on the associated teeth

37. Maxillary nerve block
 Nerve Anesthetized Maxillary division of the trigeminal
nerve.
 Areas Anesthetized
1. Pulpal anesthesia of the maxillary teeth on the side
of the block
2. Buccal periodontium and bone overlying these teeth
3. Soft tissues and bone of the hard palate and part of
the soft palate, medial to midline
4. Skin of the lower eyelid, side of the nose, cheek, and
upper lip.


38. Fig: Maxillary nerve block, High-tuberosity approach

39. Palatal Approach-Anterior Superior Alveolar
 Nerves Anesthetized: Nasopalatine, Anterior
branches of the ASA
 Areas Anesthetized:
 Pulps of the maxillary central incisors, the
lateral incisors, the canines
 Facial periodontal tissue associated with these
same teeth
 Palatal periodontal tissue associated with these
same teeth

40. Fig: Palatal Approach-Anterior Superior Alveolar
Area of needle insertion

41. THE END