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Trigeminal Nerve:
V1 and V2
Trigeminal Nerve:
V1 and V2
Alex Forrest
Associate Professor of Forensic OdontologyForensic Science Research & Innovation Centre, Griffith University
Consultant Forensic Odontologist,
Queensland Health Forensic and Scientific Services,
39 Kessels Rd, Coopers Plains, Queensland, Australia 4108
Oral Biology
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Do not remove this notice.
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Learning ObjectivesLearning Objectives
1. You should be able to understand and explain the gross
anatomy of V in detail2. You should be able to understand and explain the anatomy
of V in both structural and functional terms, showing how
these are correlated.
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Learning ObjectivesLearning Objectives
3. You should be able to understand and explain in detail the
nerve supply of the upper and lower teeth, and the
anatomical relations of the nerves involved.
4. You should understand, and be able to explain, how this
information is important in local anaesthesia in the clinical
setting, with particular reference to accessory nervesupplies to oral structures.
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Trigeminal NerveTrigeminal Nerve
The trigeminal nerve, or cranial nerve number five (V), is thecranial nerve of greatest importance to the dentist.
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Trigeminal NerveTrigeminal Nerve
It is the sensory nerve of
the front of the head andthe face.
It is also the motor nerve
that supplies motorinnervation to the
muscles of mastication,
the anterior belly of the
digastric and the
mylohyoid.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
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Trigeminal NerveTrigeminal Nerve
It provides sensory innervation to the oral cavity and to the
dental and paradental structures.
For this reason, it is branches of this nerve that are most
commonly anaesthetized so that otherwise painful dental
procedures can be performed comfortably for patients.
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
The three peripheral
divisions of the
trigeminal nerve
supply common
sensation (touch,pressure, temperature
and pain) to the skin of
the front of the face
and the scalp as farback as the vertex of
the head.
Cutaneous DistributionCutaneous Distribution
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
Cutaneous DistributionCutaneous Distribution
The ophthalmic
division (V1) supplies
the skin of the
anterior portion ofthe scalp and the
forehead, the upper
eyelid, and the front
of the nose as fardown as its tip.
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
Cutaneous DistributionCutaneous Distribution
The maxillary
division (V2) supplies
the skin at the side
of the nose, the
lower eyelid and the
upper part of the
cheek and upper lip.
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
Cutaneous DistributionCutaneous Distribution
The mandibular
division (V3) supplies
the chin and lower
lip, the skin in frontof the ear, and the
skin of the side of
the head up to the
area supplied by theophthalmic division.
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106
Cutaneous DistributionCutaneous Distribution
The angle of themandible is not
supplied by the
trigeminal nerve; it,
along with the backof the head and
much of the neck, is
supplied by cervical
nerves C2 and C3.
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Central ConnectionsCentral Connections
The unipolarsomatic
sensory cells of the
trigeminal nerve do nothave their cell bodies
located in the central
nervous system.
Instead, they are found in
the trigeminal ganglion in
the same way that the cell
bodies of spinal somaticsensory cells are located
in the dorsal root ganglion
of a spinal nerve.Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1107
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Central ConnectionsCentral Connections
The fibres terminate
in the only nuclei for
general sensation inthe brainstem, the
spinal nucleus and
the chief sensory
nucleus.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 953
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Central ConnectionsCentral Connections
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 953
Proprioceptive fibres are
important in various reflex
responses involving thejaws, and because they
need to be able to act very
fast, these are the only
peripheral sensory cells in
the body whose cell bodies
are located within the
central nervous system.They lie in the
mesencephalic nucleus.
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Central ConnectionsCentral Connections
Motor cells of the
trigeminal nerveoriginate in the
trigeminal motor
nucleus.
Modified from: From Grays Anatomy, Longman, London, 38th
Edition, 1989. p 953.
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The Ophthalmic Division (V1)
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Ophthalmic Division (V1)Ophthalmic Division (V1)
The ophthalmic division, or V1 as it is commonly known (for
division "1" of "V", the fifth cranial nerve), is purely a sensory
nerve. It contains no somatic motor fibres at all.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101
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V1 OriginsV1 Origins
It originates in and
around the orbit andforms three main
branches, which pass
into the cranium
through the superior
orbital fissure, and join
up with each other to
run in the lateral wallof the cavernous sinus
with three other cranial
nerves (III, IV and VI).Grays Anatomy, Longmans, London, 38th Ed 1989 p. 803
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V1 BranchesV1 Branches
There are three major peripheral branches of this nerve, and
each of those has several further branches:
Frontal Nerve
Lacrimal Nerve
Nasociliary Nerve
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The frontal nerve runs
across the top of the
orbit, and as it comescloser to the face, it
divides into two major
branches.
These are the
supraorbital nerve and
the supratrochlear
nerves.
Grays Anatomy, Longmans, London,
38th Ed 1989 p. 1098
V1 BranchesV1 Branches
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Grays Anatomy, Longmans, London,
38th Ed 1989 p. 1098
The supraorbital nerve
emerges onto the face
through thesupraorbital foramen
(sometimes this is just
a notch rather than afull-blown foramen),
and runs up onto the
forehead to supply the
tissues of theforehead and scalp.
V1 BranchesV1 Branches
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Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098
The supratrochlear
nerve runs more
medially and emerges
from the orbit close toits medial edge.
Here it runs up to
supply the medialportion of the upper
eyelid and the skin of
the forehead and scalp
towards the medial
aspect of the forehead
and the skin above the
root of the nose.
V1 BranchesV1 Branches
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Grays Anatomy, Longmans, London,
38th Ed 1989 p. 1098
The lacrimal nervesupplies the
conjunctiva and skin of
the lateral side of the
upper eyelid and the
lacrimal gland with
common sensation.
The secretomotor
nerves to the lacrimal
gland are passed to
the lacrimal nerve fromthe maxillary division
of the trigeminal nerve.
V1 BranchesV1 Branches
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Hence the statement that the ophthalmic nerve is purely a
sensory nerve remains correct. It simply receives
communication from another source, but the motor nerves do
not originate with the ophthalmic nerve.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1100
V1 BranchesV1 Branches
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In fact, they do not even originate with the trigeminal nerve, but
instead with the facial nerve (VII) via the greater superficial
petrosal nerve and the pterygopalatine ganglion.
This is a phenomenon to which we will become used - the
ability of certain groups of nerve fibres to "hitch a ride" with any
passing nerve trunk that is convenient and is heading in the
correct direction.
V1 BranchesV1 Branches
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Grays Anatomy, Longmans, London,38th Ed 1989 p. 1098
The nasociliary nerve
supplies the more medial
structures associated
with the orbit.
These include the lining
membranes of the
sphenoidal and ethmoidalsinuses, the tissues of
the roof of the nose and
the skin over the front of
the nose down as far as
its tip.
V1 BranchesV1 Branches
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You should make
an effort to
understand how the
nerves that radiatefrom the orbit
beneath the skin
contribute to the
pattern of
cutaneous nerve
sensation in the
area supplied byV1.
Modified from: Evers H &
Haegerstam G. Introduction to
Dental Local Anaesthesia.,
Mediglobe SA, Fribourg, 2nd Ed.1990, p. 12.
V1 BranchesV1 Branches
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The Maxillary Division (V2)
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The maxillarydivision of the
trigeminal nerve,
often known simply
as the maxillary
nerve, also contains
only sensory fibres.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973
p. 1005
The Maxillary Division (V2)The Maxillary Division (V2)
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The nerve originates
from the trigeminal
ganglion as itsintermediate branch,
lying between those of
V1 and V3.
It runs forward in the
middle cranial fossa in
the lateral wall of the
cavernous sinus andpasses out of the
cranium through
foramen rotundum. Modified from Grays Anatomy, Longmans, London, 38th Ed 1989p. 1107
The Maxillary Division (V2)The Maxillary Division (V2)
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Just before it runs through the foramen, it gives off a smallbranch to supply the dura mater of the middle cranial fossa.
The Maxillary Division (V2)The Maxillary Division (V2)
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Once it enters foramen
rotundum, it passes
through the bone toemerge in the
pterygopalatine fossa.
Illustrated Handbook in Local Anaesthesia,
Ed: E. Eriksson, Munksgaard, Denmark,
1969, p.66.
The Maxillary Division (V2)The Maxillary Division (V2)
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When it reaches the pterygopalatine fossa, it gives off a
number of branches.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006
The Maxillary Division (V2)The Maxillary Division (V2)
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Lying inferior to the nervetrunk is a parasympathetic
ganglion called the
pterygopalatine ganglion.
Two branches from the nerve
pass towards this, and
subsequently continue
through the ganglion to formfurther branches within the
pterygopalatine fossa.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973 p. 1005
The Maxillary Division (V2)The Maxillary Division (V2)
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The main trunk of the nerve,
however, continues anteriorly
to run through the inferior
orbital fissure (be sure youunderstand how this relates to
the pterygopalatine fossa by
looking at a skull), and
changes its name to theinfraorbital nerve.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973 p. 1005
The Maxillary Division (V2)The Maxillary Division (V2)
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It sinks down into a depressed
groove in the orbital surface of
the maxilla where it often gives
off a middle superior dental
nerve, and this groove
eventually roofs over to formthe infraorbital canal.
The nerve runs through this
canal, and eventually emerges
on the facial surface of the
maxilla through the infraorbital
foramen.Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973 p. 1005
The Maxillary Division (V2)The Maxillary Division (V2)
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Here it gives of branches to
the upper lip, lower eyelid
and the side of the nose.
In the canal, the infraorbital
nerve gives off the smallanterior superior dental
nerve, the nerve supply to
the upper anterior teeth,
running in canaliculus
sinosus.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973 p. 1005
The Maxillary Division (V2)The Maxillary Division (V2)
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The branches of the maxillary nerve in the pterygopalatine
fossa include:
posterior superior dental nerves
palatine nerves
sphenopalatine nerves (nasal nerves)
pharyngeal nerves
zygomatic nerve
The Maxillary Division (V2)The Maxillary Division (V2)
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The Posterior Superior Dental NervesThe Posterior Superior Dental Nerves
The posterior superior dentalnerve ornerves (there are
usually several) contribute to
the nerve supply of the upper
teeth.
They run downwards on the
back of the maxilla and pass
into the bone through aseries of small foramina.
Modified from Grays Anatomy, Longmans,
London, 35th Ed 1973 p. 1005
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Here they run into the body of
the maxilla, and reach the
lining tissue of the maxillarysinus which they supply with
sensory nerve endings.
From here, the fibres aredistributed further to form the
molar part of the nerve plexus
that supplies the upper teeth.
This is known as the superior
dental nerve plexus.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005
The Posterior Superior Dental NervesThe Posterior Superior Dental Nerves
SS
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Small nerve twiglets are also supplied to the gingivae on the
buccal aspect of the molar teeth, and also to the superior
portion of the cheek in the molar area.
Because the same nerves that supply the teeth also supply the
maxillary sinus lining, the pain of maxillary sinusitis is often
referred to the upper teeth, especially in the premolar area.
The Posterior Superior Dental NervesThe Posterior Superior Dental Nerves
Th P l ti NTh P l ti N
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The Palatine NervesThe Palatine Nerves
The palatine nerves, as their names imply, provide somaticsensory nerve supply to the palate, and parasympathetic
secretomotor nerves to the minor salivary glands contained in
the palatal mucosa.The somatic fibres originate at first in the branches of the
maxillary nerve that extend into the pterygopalatine ganglion,
and emerge from this without having synapsed, because they
are somatic sensory nerve fibres which do not synapse along
their length.
The Palatine NervesThe Palatine Nerves
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The Palatine NervesThe Palatine Nerves
While the fibres that will become the palatine nerve are in theganglion however, some post-ganglionic parasympathetic
secretomotor fibres from the ganglion get picked up and run
with them to be distributed to the minor salivary glands. The
nerve also contains some taste fibres.
Modified from
Grays
Anatomy,
Longmans,
London, 35th
Ed 1973 p.
1006
The Palatine NervesThe Palatine Nerves
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The Palatine NervesThe Palatine Nerves
Modified from
Grays
Anatomy,
Longmans,
London, 35th
Ed 1973 p.
1006
Some branches of the palatine nerve emerge through thelesser palatine foramina in the palatine bones, and these are
termed the lesser palatine nerves. They provide taste fibres,
secretomotor fibres and common sensation to the tissues of the
soft palate.
The Palatine NervesThe Palatine Nerves
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The Palatine NervesThe Palatine Nerves
Modified from
Grays
Anatomy,
Longmans,
London, 35th
Ed 1973 p.
1006
The remainder pass through the greater palatine foramen andbecome the greater palatine nerves, running forwards in the
palate to approximately the level of the canine tooth, where they
meet and anastomose with the fibres of the long
sphenopalatine nerve.
Th P l ti NTh P l ti N
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The Palatine NervesThe Palatine Nerves
Because the palatal tissues are supplied by these nerves, weneed to anaesthetize them if we wish to extract a palatal tooth,
because otherwise the palatal gums will remain sensitive.
The Sphenopalatine NerveThe Sphenopalatine Nerve
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The Sphenopalatine NerveThe Sphenopalatine Nerve
The sphenopalatine nerve passes medially into the
sphenopalatine foramen, which lies in the deepest part of the
pterygopalatine fossa.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006
The Sphenopalatine NerveThe Sphenopalatine Nerve
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The Sphenopalatine NerveThe Sphenopalatine Nerve
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006
After passing through the foramen, the nerve gives off some
small lateral branches (short sphenopalatine nerves) which are
distributed over most of the lateral wall of the nasal cavity.
The Sphenopalatine NerveThe Sphenopalatine Nerve
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The Sphenopalatine NerveThe Sphenopalatine Nerve
The long sphenopalatine or nasopalatine nerve crosses the roof
of the nasal cavity and descends on the nasal septum to supply
the overlying mucous membrane.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 997
The Sphenopalatine NerveThe Sphenopalatine Nerve
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The Sphenopalatine NerveThe Sphenopalatine Nerve
The nerve continues through the incisive canal to communicate
with the greater palatine nerves. Small twigs help to supply the
palatine supporting structures of the central and lateral incisors.
Modified from: Illustrated
Handbook in Local
Anaesthesia, Ed: E.
Eriksson, Munksgaard,Denmark, 1969, p.66.
The Pharyngeal NervesThe Pharyngeal Nerves
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The Pharyngeal NervesThe Pharyngeal Nerves
The pharyngeal nerves supply the mucous membrane of the
upper nasopharynx.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006
The Zygomatic NerveThe Zygomatic Nerve
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The Zygomatic NerveThe Zygomatic Nerve
The zygomatic nerve runs
into the orbit through the
inferior orbital fissure like the
infraorbital nerve, but instead
of running across the floor of
the orbit, it runs on the lateral
wall on the zygomatic bone,from which it takes its name.
It also picks up some fibres
from the pterygopalatineganglion.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973
p. 1005
The Zygomatic NerveThe Zygomatic Nerve
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The Zygomatic NerveThe Zygomatic Nerve
It divides into two branches, the zygomaticotemporal nerve
and the zygomaticofacial nerve which run into the zygomaticbone through two small foramina, and these emerge through
foramina which take the names of the nerve branches.
The Zygomatic NerveThe Zygomatic Nerve
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The Zygomatic NerveThe Zygomatic Nerve
The parasympathetic secretomotor fibres from thepterygopalatine ganglion travel in this branch of the nerve, and
they run to the lacrimal nerve of V1, travelling along it to the
lacrimal gland, and constitute most of its parasympathetic
secretomotor innervation.
Lacrimal Branch
Modified from
Grays Anatomy,
Longmans,
London, 35th Ed
1973 p. 1005
The Infraorbital NerveThe Infraorbital Nerve
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The Infraorbital NerveThe Infraorbital Nerve
The important
branches of the
infraorbital nervewithin the orbit are
the middle superior
dental nerve and the
anterior superiordental nerve, which
contribute to the
superior dental
plexus.
Modified from Grays Anatomy,
Longmans, London, 35th Ed 1973
p. 1005
Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
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Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
As we haveseen, the nerve
supply to the
dental pulps of
the upper teethand the nerve
supply to the
maxillary sinus
are closelyrelated.
http://www.septodont.ca/Septodont/english/other/cea_di01.html
Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
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Uppe eet e e Supp yUppe eet e e Supp y
The superior
dental plexus isformed by
twiglets from the
posterior superior
dental nerve, theanterior superior
dental nerve, and
the middle
superior dentalnerve when it is
present.
http://www.septodont.ca/Septodont/english/other/cea_di01.html
Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
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pp pp ypp pp y
When the middle superior dental nerve is present, fibres fromthe posterior superior dental nerve supply the molar teeth and
a twig to the second premolar.
The middle superior dental nerve fibres supply themesiobuccal root of the upper first molar, the premolars, and
may jointly supply the canine tooth.
The anterior teeth as far back as the first premolar have
twiglets from the anterior superior dental nerve.
Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
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pp pp ypp pp y
When the middle superior dental nerve is not present, then
the upper posterior teeth as far back as the second premolarare supplied with twiglets by the posterior superior dental
nerve, and anterior teeth as far back as the second premolar
are supplied by the anterior superior dental nerve.
Upper Teeth Nerve SupplyUpper Teeth Nerve Supply
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pp pp ypp pp y
There is no difference in the degree of sensitivity of the teeth
regardless of the presence or absence of the middle superior
dental nerve.
The adjacent buccal gingivae are supplied by the same nerves
that supply the dental pulps of the adjoining teeth.
Upper Teeth AnaesthesiaUpper Teeth Anaesthesia
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If pulpal anaesthesia is required, for example for a filling, then
anaesthesia of these nerves is all that is required.
If anaesthesia is required for extraction, however, then thenerve supply of the palatal tissues must also be
anaesthetized, since these will be surgically detached during
the procedure.
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The End