Anatomy, Head and Neck, Alveolar Nerve


Article Author:
John Nguyen


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Updated:
9/6/2019 10:14:42 PM

Introduction

One of the first features of the human body to be noticed by another person is the face. The face is made up of many different muscles, nerves, bones, and organs, and has an intriguing network of motor and sensory innervation. The motor innervation to the muscles located in the face is derived mainly from the facial nerve (CN VII) and trigeminal nerve (CN V). The facial nerve provides innervation to the muscles that are involved in creating facial expressions, whereas the trigeminal nerve innervates the muscles used in mastication.

The sensory innervation of the face comes from the trigeminal nerve. The trigeminal nerve subdivides into three main branches that split the face into three territories. The first branch from the trigeminal nerve is the ophthalmic nerve (CN V1). The ophthalmic nerve provides innervation to the forehead, eyes, and nose. The second branch of the trigeminal nerve is the maxillary nerve (CN V2). The maxillary nerve's sensory innervation follows the maxilla bone. The sensory territory of the maxillary nerve will be the cheeks and the upper lip mainly. The last branch from the trigeminal nerve is the mandibular nerve (CN V3). The mandibular nerve is responsible for providing sensory innervation to the regions that correspond to the mandible. These regions are the jawline, chin, and lower lip.

The branches of the trigeminal nerve will further divide into smaller nerve branches to optimally provide sensory innervation to their respective territories. For example, the maxillary nerve will branch into the superior alveolar nerves. Another example is the mandibular nerve branching into the inferior alveolar nerve. The inferior alveolar nerve will be responsible for sensory innervation to the cheek, lips, chin, teeth, and gingivae. 

Structure and Function

The sensory territories for the alveolar nerves divide between the superior alveolar nerves and the inferior alveolar nerves. The superior alveolar nerves will come from the branching of the maxillary nerve. The maxillary nerve will branch into the three superior alveolar nerves before it exits the infraorbital foramen. The superior alveolar nerves are named based on their anatomical location. The first branch is the anterior superior alveolar nerve. The anterior superior alveolar nerve travels toward the maxillary sinus. The sensory innervation of the anterior superior alveolar nerve includes the premolars (canine teeth and incisor teeth), maxillary sinus, and inferior meatus. The second branch of the maxillary nerve is the middle superior alveolar nerve. The middle superior alveolar nerve is responsible for providing addition sensory innervation to the sinuses and the maxillary premolar teeth. The third branch of the maxillary nerve is the posterior superior alveolar nerve. The posterior alveolar nerve provides sensory innervation to the cheeks, maxillary sinus and the gingivae. All of the alveolar nerve branches from the maxillary nerve provide sensory innervation to the gingivae and sinuses. These superior alveolar nerves have overlaps in their sensory territory innervation with one another. This provides collateral sensory innervation via a dental nerve plexus.[1]

The inferior alveolar nerve comes from a different branch of the trigeminal nerve. The inferior alveolar nerve is a mandibular nerve branch. The inferior alveolar nerve is responsible for sensory innervation to the gingivae on the lower jaw. The inferior alveolar nerve also branches into the mylohyoid nerve and the mental nerve. As the inferior alveolar nerve descends the mandible, it will branch into the mylohyoid nerve to provide motor innervation to the mylohyoid muscle and the anterior belly of the digastric muscle.[2] The inferior alveolar nerve will then travel in the mandibular foramen until it reaches the mental foramen. Once at the mental foramen, the inferior alveolar nerve exits and becomes the mental nerve. The mental nerve is responsible for innervating the chin, lower lip, and the gingivae.[3]

Embryology

During embryology, the development of peripheral nerves derives from neural crest cells. The development of the structures in the face originates from the brachial apparatus. The brachial arch is made up of mesoderm and neural crest cells. The brachial arch will form the muscles, nerves, and bones in the face and neck. The first brachial arch will develop the first two branches of the trigeminal nerve. The maxillary nerve and the mandibular nerve and their innervation territories will form from the first brachial arch. As the face develops the maxillary nerve and mandibular nerve will branch into their respective alveolar nerves, which means the alveolar nerves are derivatives of neural crest cells.

Blood Supply and Lymphatics

The proximal blood supply to the maxillary nerve and the mandibular nerve at the region of the pons is the anterior inferior cerebellar arteries.[3] The distal blood supply to the maxillary, the mandibular nerve, and their nerve branches are from the external carotid artery. The external carotid artery is responsible for the perfusion of the external head and face. The distal blood supply also provides perfusion to the alveolar nerves. The blood supply to the trigeminal nerve will be from the basilar artery, cerebellar arteries, and the vertebral arteries.[4] 

The lymphatic drainage of the alveolar nerves and their sensory territories is toward the submental lymph nodes, the submandibular lymph nodes, and the preauricular lymph nodes. The lymph fluid will eventually be drained back into the right lymphatic duct and the thoracic duct. The right side of the face will drain into the right lymphatic duct, and the left side of the face will empty into the thoracic duct. Finally, the lymph in the right lymphatic duct and the thoracic duct will drain back to the central circulation.

Nerves

The alveolar nerves separate into the superior alveolar nerves and the inferior alveolar nerves. The superior alveolar nerves originate from the maxillary branch of the trigeminal nerve. The superior alveolar nerves divide into the anterior, middle, and posterior superior alveolar nerves. While the inferior alveolar nerve originates from the maxillary branch of the trigeminal nerve, the alveolar nerve will branch into the mental nerve. All of these alveolar nerves and their subdivisions will contribute to sensory innervation to the face and mouth.

Muscles

The maxillary nerve and the mandibular nerve provide motor innervation to the muscles involved in mastication. While the alveolar nerves are branches of the maxillary nerve and the mandibular nerve, they are purely sensory to the face and mouth.

Physiologic Variants

The superior alveolar nerves are three branches that come from the maxillary nerve. Numerous variations exist with the superior alveolar nerves. The origin, path, and branching patterns vary considerably.  In some individuals, the dental plexus formed by the superior alveolar nerves maybe be larger or smaller. Some individuals may lack one of the superior alveolar nerve branches. For example, the middle alveolar nerve may be absent in some individuals.[1][5]

In contrast, the superior alveolar nerves, the inferior alveolar nerve is usually only one nerve. The inferior alveolar nerve is typically the only alveolar nerve that branches from the mandibular nerve. The origin, path, and branching pattern of this nerve can also vary. In some cases, there is a bifid inferior alveolar nerve instead of just one nerve. The inferior alveolar nerve may also have small connections to the neighboring nerves. The path in the mandibular foramen may also vary. The path variations can be due to several factors. The most common cause of the path to differ is the variable shape of the mandible, which could cause the inferior alveolar nerve to travel lower or higher in the bone itself.[3][6]

Surgical Considerations

In surgery, the knowledge of the alveolar nerves is crucial. The alveolar nerves are important in providing sensory innervation to the teeth, gingivae, lower lip, and chin. If the alveolar nerves are damaged, there may be a permanent loss of sensation in those areas.[7][8][9][10]

In both plastic and oral and maxillofacial surgery, the jaw may require reconstruction or the implantation of teeth may be necessary. It is important to reconstruct the jaw without damaging the alveolar nerves. In some dental implantations, the alveolar nerves may become translocated during the procedure.

Clinical Significance

Dentists commonly inject the superior and inferior alveolar nerves with local anesthetic for dental procedures. The knowledge of the location of these nerves will guide a successful nerve block. But it is crucial to take into consideration the many variations in the nerves. If the classic approach to the nerve block is insufficient, the operator should consider that maybe there is a slight variation in the location of the alveolar nerves.[11]

Dental pain can highlight the importance of the sensory innervation of the alveolar nerves. When a tooth or gingivae is damaged, that region will send pain signals to the brain' this is a common presentation seen in patients with cavities, cracked teeth, dental abscess, and oral ulcers.

Other Issues

Since the superior alveolar nerves are branches of the maxillary nerve, and the inferior alveolar nerve is a branch of the mandibular nerve. Any injury to the maxillary nerve, the mandibular nerve, or the trigeminal nerve can result in damage or loss of function in the alveolar nerves.[7][8]


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Anatomy, Head and Neck, Alveolar Nerve - Questions

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A 30-year-old female presents to her provider as she is planning to get her jaw reconstructed after braces failed to fix her underbite. The patient's past medical history is unremarkable. On physical examination, the patient has a significant prognathism. The surgeon explains to the patient that he will remove part of the jaw to lessen the underbite. During the procedure, the surgeon is careful to avoid damaging the nerve that innervates the lower jaw's gingivae. What opening does this nerve travel through?



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A 55-year-old man presents to the emergency department after falling and injuring himself while working on his roof. He complaints of some weakness in his jaw. His past medical history is unremarkable. On physical examination, there is mild bruising of the neck. The provider suspects the damage is affecting a muscle innervated by a branch of the inferior alveolar nerve. What is the primary action of the muscle that receives innervation from a nerve that is a branch of the inferior alveolar nerve?



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A 25-year-old female presents to the office for tooth pain. Her past medical history is unremarkable. On physical exam, there is a cracked canine tooth on the superior jaw. Tooth extraction is planed. A nerve block is applied which numbs the tooth. What nerve gives rise to the nerve being blocked?



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A 25-year-old male patient presents to the urgent care center with a swelling in his mouth. The patient states the swelling has gradually got larger over the last week. His past medical history is unremarkable. On physical exam, he is found to have a dental cavity affecting a lower incisor tooth. This cavity resulted in the abscess formation. The provider decides to drain this abscess. Before draining the abscess, the provider performs a nerve block on the nerve that gives rise to the nerve for the incisors of the lower jaw. What is the opening for the nerve that innervates the lower incisors?



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A 30-year-old male comes into the emergency department after a motor vehicle accident. The patient has sustained some facial injuries. His past medical history is significant for binge drinking. On physical exam, the patient is found to have a broken mandible and numbness in the gingivae of the upper and lower jaw. The provider suspects nerve damage. What is the embryological origin of the nerve that is causing the numbness?



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Anatomy, Head and Neck, Alveolar Nerve - References

References

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Heasman PA, Clinical anatomy of the superior alveolar nerves. The British journal of oral     [PubMed]
Wolf KT,Brokaw EJ,Bell A,Joy A, Variant Inferior Alveolar Nerves and Implications for Local Anesthesia. Anesthesia progress. 2016 Summer;     [PubMed]
Carter RB,Keen EN, The intramandibular course of the inferior alveolar nerve. Journal of anatomy. 1971 Apr;     [PubMed]
Ćetković M,Štimec BV,Mucić D,Dožić A,Ćetković D,Reçi V,Çerkezi S,Ćalasan D,Milisavljević M,Bexheti S, Arterial supply of the trigeminal ganglion, a micromorphological study. Folia morphologica. 2019 Jul 8;     [PubMed]
Kojima Y,Murouchi T,Akiba M,Oka T, Ultrasound-guided inferior alveolar nerve block for postoperative analgesia after mandibular sequestrectomy: A single-center retrospective study. Journal of clinical anesthesia. 2019 Aug 20;     [PubMed]
Toth J,Lappin SL, Anatomy, Head and Neck, Mylohyoid Muscle 2019 Jan;     [PubMed]
Kang F,Sah MK,Fei G, Determining the risk relationship associated with inferior alveolar nerve injury following removal of mandibular third molar teeth: a systematic review. Journal of stomatology, oral and maxillofacial surgery. 2019 Aug 30;     [PubMed]
Shen H,Wang S,Zhi Y,Si J,Shi J, Effects of inferior alveolar nerve rupture on bone remodeling of the mandible: A preliminary study. Medicine. 2019 Aug;     [PubMed]
Gallesio C,Berrone M,Ruga E,Boffano P, Surgical extraction of impacted inferior third molars at risk for inferior alveolar nerve injury. The Journal of craniofacial surgery. 2010 Nov;     [PubMed]
Schreiber A,Mattavelli D,Ferrari M,Rampinelli V,Lancini D,Ravanelli M,Bertazzoni G,Rodella LF,Buffoli B,Doglietto F,Nicolai P, Anterior superior alveolar nerve injury after extended endoscopic medial maxillectomy: a preclinical study to predict neurological morbidity. International forum of allergy     [PubMed]

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