In the last time we talk about the face the content the muscle ,,, etc We will speak now

about the trigimnal nerve which is the largest nerve it calssify as the 5th one mixed sensory and motor trigeminal nerve give three branches one called the ophthalmic nerve to provide sensation to the area above the orbit and the anterior part of the skull and the other one Maxillary nerve give the sensation to the area above the maxilla and Mandibualr branch to the lower part of the face . you know that the opthalmoc passes through the superior orbital fissure and maxillary through foramen rotandum and mandibular through foramen ovale

starting with the trigeminal nerve : the first branch of it is the ophthalmic nerve , it’s a sensory nerve , trigeminal nerve is made by a large sensory root and medial to this root there is a small motor root , the motor root usually discend with the third branch ( the mandibular ) that’s why the mandibular is mixed motor and sensory the remaining two are sensory

Opthalmic nerve : ( the smallest branch from the trigeminal ganglion ) It arises from the trigeminal nerve in the middle fossa , it passes forward Toward the orbit , before it reach the superior orbital fissure it divides into three branches * The first one ( the smallest one ) goes laterally toward the lacrimal gland which is the lacrimal nerve * The second one is the largest and continue to the front that’s why they call it frontal nerve because it continue the front toward the frontal bone

* The last one which is intermediate in size from ophthalmic we refer to it nasociliary nerve because it has relation to the ciliary area which is the eye ball and relation to the nose So ophthalmic divide before it reach superior orbital fissure into three branches 1- lacrimal laterally

2- in the middle frontal nerve 3- nasociliary medialy

** NOW three branches will enter through superior orbital fissure ….so what is passing through superior orbital fissure are the three branches of the ophthalmic nerve NOT the ophthalmic it self … it divide before , at the border of superior orbital fissure . so once they pass the lacrimal will continue laterally to th lacrimal gland then it will leave the lacrimal gland to outside to provide sensation to the lateral part of the upper eyelet

* T he frontal branch continue to the front and in the mid way within the orbit it divide into two branches one goes more medialy we refer to it as suratrochlear nerve and the other one continues toward the middle we refer to it as supraorbital nerve and you will see them in the face …. Supratrochlear will provide sensation to the forehead and anterior part of the scalp while the supraorbital will do the same to the forehead area , to the anterior half of the scalp ( which mean anterior part of the head sensation ) so sensation from above the orbit to the middle of the head , this all area the sensation is from supratrochlear and supraorbittal that are coming from the frontal nerve which is the largest branch of ophthalmic ** And in addition the supraorbital will provide sensation to the middle part of the upper eyrlet ..

**T he nasociliary which intermediate in size once it arrives it will go medialy to cross the optic nerve ( first cranial nerve ) .. within the orbit the nasociliary will cross superior to optic nerve , from lateral to medial and as it move, the nasociliary will give five branches

2 branches to the eye ball we refer to them as ciliary branches *the long ciliary *the short ciliary

those are carring out the sempathetic and parasympathetic innervation to the muscle controlling the pupil the sympathetic will dilate the pupil and the the parasympathetic will constrict the pupil Then as it pass it give 2branches that ganna penetrate the ethmoid bone in the medial wall of the orbit : the posterior and the anterior ethmoidal They are very important because they will provide sensation to the ethmoidal air sinus (anterior ,middle and posterior ) and to sphenoid air sinus and to the nasal wall … ** The anterior ethmoidal will go over the nose to supply the bridge of the nose , its name will become external nasal so when you look to the face You will see a nerve from the ophthalmic we call it (external nasal) this is continuation of the anterior ophthalmic nerve. So there are : 1- lacrimal nerve 2- supraorbital. 3- supratrochlear 4- external nasal nerve ( at the bridge of the nose until the tip when you touch the tip of your nose this sensation is from ophthalmic nerve. And the last branch will terminate into branch call : 5- infratrochlear nerve.

Why we call them infra and supratrochlear nerves ? Because on the medial angle of the orbit there is a trochlea (facial loop) this loop is holding the tendon of the muscle for moving the eyeball this muscle is called ( superior oblique muscle) and there is trochlea holding that muscle , so the nerve that pass from the frontal above the trochlea wee call it>> Supratrochlear (frontal branch), the one that pass from below the trochlea we call it ( infratrochlear nerve) >> which is nasocelliare (I'm not sure of the spelling).

So infratrochlear an external nasal bone are branches from nasocelliary.

The second nerve which provide sensation to the face is the maxillary nerve . Maxillary nerve follows the role of 3 >> gives 3 branches to 3 different areas:

1- 3 branches to the palate :

A - grater palatine nerve to the hard palate . B - lesser palatine nerve to the soft palate . C- INCISIVE nerve to the primary palate.

2- 3 branches to the teeth.

3- 3 branches to the face :

A- Infraorbital : below the orbit and it is continuation of the maxillary nerve >> and it gives sensation to the skin of the lowe eyelid over the maxillary and even it reaches to upper limb mucosa >> so when you do extraction for upper teeth you have to anesthetize it because because the exracton including soft tissue damage. B- 2 brancehs from zugomatic bone : there are 2 foramina in zygomatic bone the first one will come from zygomatic bone towards the face so wee call it ( zygomatico-facial ). C- The other one from the zygomatic but up towards the temporal area so we call it (zygomatico-temporal).

Whats the different between hard and soft palate? The primary palate is the area that containing the rogues (‫ )تعرجات‬folds on the upper mucosa of the palate ( the area behind the anterior teeth ).

So three branches to the palate , three branches to the face and three to the upper teeth . those branches ( that are reffering to the upper teeth ) will call them the superior alveolar nerve … - posterior superior alveolar to the molars , - middle superior alveolar to the premolars , -anterior superior alveolar to the anterior teeth ( canine and incisors )

For the mandibular nerve …
NOW when we speak about the mandibular nerve the doc give us a paper that summarize the branches of mandibular nerve it is in the last of the script ..

Mandibular nerve is the largest branch from the trigeminal ganglion ( trigeminal nerve ) the mandibular branch desend through foramen ovale ,when it desend it desend like a trunk ( ‫(جذع‬ ‫ … الشجرة‬when the trunk divide into large divisions anterior and posterior divisions … the anterior division is much much smaller than the posterior division so when you look the main truck , it is (2-3)mm in length …. after that there is a small anterior division and there is a large posterior division .. - from the main truck you have two branches one sensory and one motor - from the anterior division there are four : 3 motor and one sensory - from the posterior there are four : also but one motor and three sensory

what are these branches ? first the total number of them is 10

The branches from the main trunk are :

1- The sensory one : Recurrent meninegial branch first the trunk will go posteriorly then it will enter the foramen that behind foramen ovale and middle meningial artery enter from it which is foramen spinosum ,this nerve is a sensory nerve that will go back and return to get inside the skull through foramen spinosum . once its inside the skull it will provide sensory innervation to the dura matter ( part of the meninges that cover the brain ) so we call it recurrent meninegial branch or nervous spinosus because its get through spinosum to the meninges in the middle cranial fossa .

2- The other branch from the trunk is the motor one which is called nerve to medial teregoid that innervates the medial pterygoid ( remember : we have four muscle of mastication 2 from outside the masseter and temporalis and 2 from inside of the mandible which are lateral pterygoid and medial pterygoid ) so one of the muscles of mastication get the innervation from the nerve to medial pterygoid , also nerve to medial teregoid will give branches to 2 other muscles 2 tensors in you body we call them tensor tempani and tensor veli palatine muscle …

The anterior division
- 3 motor for the remaining muscles of mastication Temporalis .. deep temporal nerve Masseter ,….. masseteric nerve Lateral pterygoid.. nerve to lateral pterygoid

- 1 sensory goes to the cheek ,it descend all the way anterior inferior to arrive the cheek it gives sensation to the skin over the cheek , to the oral mucosa inside your mouth in the cheek area and to buccal gingiva of the lower molar teeth .. This branch is called the buccal nerve of trigeminal because its going to the cheek ( we mention nerve of trigeminal to distinguish it from bacalao facial which is motor of bacsenator )

The posterior division
- 3 sensory : 1- Auriculotemporal it goes to the auricle and to the temple ( lateral aspect of the skull we call it also the skin over the temple ) so from its name to the auricle and over the temporal bone

2- The second one give general sensation to the tongue ( lingual nerve )

* what is the difference between general and special in the tongue ? the special is the taste sensation and the general is the thermal ,the pain the touch and the pressure .. So all of these 3 are general sensation and are carried by this branch which is the lingual nerve because it is going to the tongue , * so we have the most posterior it go with 2 roots all the way back then up , this is the auricle temporal * the most anterior to the tongue which is the lingual , it gives general sensation from the anterior two third of the tongue .

3- The one in between descend all the way and enter the mandible to innervate the lower teeth which is the inferior alveolar nerve ..

so three large sensory branches : lingual anteriorly , inferior alveolar from the middle , auriclotemporal the most posterior one ..

-1 motor nerve to mylohyoid it goes indirectly from the posterior division , actually direct branch from inferior alveolar .. before it enters into the ramus of the mandible it give this smalll branch that goes all the way to innervate mylohoid and anterior belle of digastric ( the floor of the mouth )

so three again
* sensory lingual to the tung … * the inferior alveolar to the lower teeth * the auriclotemporal which is a very important sensory nerve because its ganna supply different structures five

1- auricle ( the outer surface of your auricle of your ear ) 2- the skin over the temple ( lateral skull ) 3- external auditory meatus 4- the tympanic membrane ( external surface ) 5- the TMJ tempromandibular joint “the most important to us as dentists”

The tympanic membrane :the part of ear that changes the sound waves into vibrations then those will become nerve signals in the inner ear. ‫طبلة االذن‬

The motor branches of the main trunk “nerve to medial terigoid” innervates : medial terigiod and 2 tensors

Auriculo temporal buccal “mental nerve inf alveolar nereve” **Its going to be repeated in the next lec.s Arterial blood supply to the face: 1 - facial artery : the main artery to the face from the external carotid artery, feel it pulse on the lower border of the mandible in the face it gives branches : 1- Inferior labial: to the lower lip 2- Superior labial: to the upper lip 3- lateral nasal: to the nose 4- the angular artery : cuz it terminate at the angle between the eye and the nose

muscle relations “important” :it passes superficial to the buccinators m. and the levator anguli oris m. (elevates the angles of the mouth) , And deep to zygomaticus major and minor muscles & levator labii superioris m. in the end it appears as sandwiched between facial muscles to get deep as possible as it can. 2 – Superficial temporal artery: assending up to the lateral aspect of the scalp and gives a branch that goes transversely into the face “transverse facial artery” ** there are several small branches “you can read them by your self. Veins of the face: 1- Facial vein: To the internal jugular vein (IJV) 2- superficial temporal vein: transverse facial vein drain in it then then the superficial temporal inter inside the parotid gland to unites with the maxillary v. to become retro mandibular v. behind the mandible 3- retro mandibular vein: from behind the neck of the mandible to the angle of the mandible here it divides into 2 divisions “anterior and posterior retro mandibular” the anterior one joins the facial vein that will go and drain into the IJV , but the posterior one joins the posterior auricular to form the EJV that will cross the posterior triangle of the neck.

SUMMERY: Nerves of face : ❶Post. auricular n. ❷Temporal ❸Zygomatic ❹Buccal ❺Mandibular Cervical

1- Ophthalmic n. (V1) ❶ supratrochlear ❷supraorbital ❸lacrimaln ❹ifratrochlear ❺external nasal 2- Maxillary n. (V2) ❶infraorbital ❷zygomatico-facial ❸zygomatico-temporal

3- Mandibular n. (V3) ❶auriculotemporal ❷buccal of mandibular ❸mental n. The area in the face that doesn’t reserve sensation from the trigeminal nerve is at the angle of the mandible “the great auricular nerve” originates from C2, C3.

Arteries of face : Facial a. ❶sup. & inf. labial a. ❷lateral nasal a. ❸Angular a.

Veins of face : 1. Facial vein 2. Superficial temporal vein 3. Retromandibular vein:

the SCALP “‫“ فروة الرأس‬
it made up of 5 layers each layer is indicated by a letter of the word scalp: S: Skin C: Connective tissue A: Aponeurosis (flat tendon) L: Loose C.T.: to allow the movement of the tissue P: Periosteum: dense C.T. that firmly attached to the bone from outside

Extensions: From the external occipital protuberance all the way anteriorly to the supra orbital margins and laterally from the zygomatic arches and above.

the skin 1-layer is very thin except over the occipital bone because of the presence of the muscles there. 2- it contains a lot of hair follicles sweat glands and sebaceous glands. 3- it is rich in blood supply. The second layer is CONNECTIVE TISSUE LAYER, it is very important because the blood supply (artery &veins) pass through this layer. NOTE: there is 2 important areas in our body ,that are consider the richest areas in blood supply: 1-the scalp 2-the nasal cavity that is why if you have an injury in one of these 2 areas ,you will have a sever bleeding. APONEUROSIS it has more than one name: 1-epicranial aponeurosis ( above the cranium) 2-galea aponeurotica (galea :mean helmed ‫) واقي‬ it is very important because it provides protection for the under laying tissue ,also it provides a muscular attachment : 1-posteriorly << occipitalis muscle

2- anteriorly<< frontalis muscle 3-laterally << superior auricular muscle After the aponeurosis there is a tissue and many spaces which is called connective tissue layer (so the skin & C.T layer & aponeurosis together) so when the aponeurosis move , it will cause movement to another layers (skin&CT layer) SO, these 3 layers called SCALP PROPER ( the main part of the scalp) LOOSE CONNECTIVE TISSUE it has too many spaces (spongy like layer) << to allow free movement for the scalp proper PERIOSTEUM outer CT layer that is firmly attached to the bone (it is part of the bone actually)

INNERVATION TO THE SCALP: **anteriorly <<< supratrochlear & supraorbital nerves <<< from ophthalmic nerve. **posteriorly <<< lesser occipital (from anterior ramus of C2) & greater occipital (from posterior ramus of C2) **laterly <<< auriculotemporal never (from division of mandibular nerve) & zygomatictemporal nerve (from maxillary nerve).

THE BLOOD SUPPLY TO THE SCALP: anteriorly << supratrochlear artery & supraorbital artery. once the ICA being in the skull ,it will give a branch go to the orbit , this branch will supply everything in the orbit ,and it is called OPHTHALMIC ARTERY ,this artery will terminate into : 1- supratrochlear artery 2- supraorbital artery Laterally :

ICA << internal carotid
artery . ECA<< exernal carotid artery

1- there is a small one from ophthalmic artery called zygomaticotemporal artery 2-there is main one which is superficial temporal artery (which is termination of ECA) Posteriorly :

1- posterior auricular artery. 2- Occipital artery. Both from ECA. So, the first 3 arteries (anteriorly) from ICA, and the last 3 arteries (posteriorly) from ECA. That is why the scalp very rich area in blood supply, because all blood supply from ECA&ICA will meet in the scalp and this meeting will look like network (arterial plexus), so any small injury there, it will cause a severe bleeding. WHAT IS COMPLICAT THAT??? Because of the presence of the tendon (aponeurosis), if you have an injury, and there is a cutting in the tendon, there will be RETRACTION for a long distance, so the part of aponeurosis attaches to frontalis muscle, will go anteriorly. And the part of aponeurosis attaches to occipitalis will go posteriorly. This retraction will cause a difficulty to do a spontaneous healing and this will lead to prolonged bleeding. SO, small injury in the scalp will result in a sever prolonged bleeding due to : 1-rich blood supply 2- separation of vessel ends by C.T septa & the aponeurosis. The only way to stop the bleeding in the scalp is = suturing the injury of the scalp. SCALP INFECTION - Pus or blood spreads easily in the loose connective tissue layer of SCALP (Danger area of scalp) Infection or fluid in this layer (pus or bld.) cannot pass posteriorly or laterally, only anteriorly WHY ??? ***POSTERIORLY the occipitalis muscle attaches to the bone (BUT anteriorly the frontails muscle doesn’t attach to the bone, it attaches to the skin). So the infection very easily to go anteriorly because there is no bony attachment, so it will go anteriorly and accumulated there in eye area and causes BLACK EYE or ECCHYMOSIS The most complex condition of this infection, that if there is infection, it is very easily to transport the infection from outside the skull to inside (to the MENINGES) through 2 important openings in parietal bone called parietal foramina, through these foramina there is 2 important veins pass through them called EMISSARY VEINS (those veins make a communication between veins outside the skull with the vein inside the skull).

SO, if there is infection, it is very easily to spread the infection from outside to inside through emissary veins and producing what is called MENINGITIS (inflammation of the meninges).

*** ALSO, the infection of the scalp can’t go laterally, because the scalp attach to the zygomatic arches (y3ne there is a bony attachment also)

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