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Maxillary nerve

The maxillary nerve (CN V₂), also known as the maxillary division of the trigeminal nerve, is the intermediate and purely sensory branch of cranial nerve V, providing general somatic afferent fibers for sensations of touch, pain, and temperature from the midfacial region, including the skin of the lower eyelid, side of the nose, cheek, and upper lip, as well as the upper teeth, maxillary sinus, nasal cavity mucosa, and hard palate.^[1]^[2] Originating from the anterior aspect of the trigeminal ganglion within the middle cranial fossa, the maxillary nerve initially courses anteriorly along the lateral wall of the cavernous sinus without synapsing, then exits the skull base through the foramen rotundum to enter the pterygopalatine fossa.^[3]^[2] From this fossa, it communicates with the pterygopalatine ganglion via ganglionic branches. The main trunk then continues anteriorly as the infraorbital nerve, entering the orbit via the inferior orbital fissure, where it travels within the infraorbital groove and canal to emerge onto the face through the infraorbital foramen.^[3]^[2] The maxillary nerve gives rise to several key branches along its path, including the meningeal branch (supplying the dura mater of the middle cranial fossa), zygomatic nerve (which further divides into zygomaticotemporal and zygomaticofacial branches for skin innervation over the temple and zygomatic bone), posterior superior alveolar nerves (providing sensory input to the maxillary molar and premolar teeth, as well as the maxillary sinus), and pterygopalatine nerves (distributing via the pterygopalatine ganglion to the orbital periosteum, nasal mucosa via posterior nasal nerves, and palatal mucosa via greater and lesser palatine nerves).^[3]^[2] The terminal infraorbital nerve then branches into inferior palpebral (lower eyelid skin), external nasal (side of nose), internal nasal (nasal septum), and superior labial nerves (upper lip skin and mucosa).^[2] These distributions make the maxillary nerve essential for facial sensation and a target for local anesthesia in maxillary dental procedures.^[1]

Anatomy

Origin and general course

The maxillary nerve, also known as the second division (V2) of the trigeminal nerve (cranial nerve V), originates from the anterior convexity of the trigeminal ganglion, which is situated within Meckel's cave on the petrous apex of the temporal bone.^[1] This ganglion serves as the sensory root hub for the trigeminal nerve, and the maxillary division emerges between the ophthalmic (V1) and mandibular (V3) divisions.^[4] From its origin, the maxillary nerve travels anteriorly, embedded in the lateral wall of the cavernous sinus alongside other cranial nerves, before exiting the middle cranial fossa through the foramen rotundum to enter the pterygopalatine fossa.^[1] It then proceeds superiorly through the inferior orbital fissure into the floor of the orbit, where it courses anteriorly along the infraorbital groove and through the infraorbital canal within the orbital floor.^[5] The nerve ultimately exits the skull onto the face via the infraorbital foramen, located below the orbit on the maxillary bone.^[1] This trajectory has a general diameter of about 3-4 mm, varying slightly along its path.^[6]^[7] Microscopically, the maxillary nerve is a purely sensory nerve bundle composed of myelinated and unmyelinated axons originating from pseudounipolar neurons, whose cell bodies reside in the trigeminal ganglion; these fibers convey general somatic afferent signals without motor components.^[1]

Relations to surrounding structures

Within the middle cranial fossa, the maxillary nerve travels along the lateral wall of the cavernous sinus, positioned inferior and lateral to the ophthalmic division of the trigeminal nerve and in close proximity to the oculomotor and trochlear nerves, while being adjacent to the internal carotid artery and the abducens nerve as it approaches the foramen rotundum. This positioning is critical for surgical approaches to the cavernous sinus, where inadvertent manipulation could risk vascular or neural compromise. The nerve exits the cranium through the foramen rotundum, a key landmark for endoscopic transsphenoidal procedures.^[1]^[3]^[2] Upon entering the pterygopalatine fossa, the maxillary nerve lies superior to the pterygopalatine ganglion, from which it sends sensory branches, and is situated alongside branches of the maxillary artery, such as the posterior superior alveolar artery, facilitating coordinated neurovascular supply to the midface. Laterally, it relates to the sphenopalatine foramen, through which its branches extend into the nasal cavity, emphasizing the fossa's role as a conduit for both neural and vascular elements in sinonasal surgeries. The fossa itself is a confined pyramidal space bounded anteriorly by the maxilla, posteriorly by the sphenoid, and medially by the palatine bone, providing bony protection while highlighting the need for precise imaging in interventions like pterygopalatine ganglion blocks.^[1]^[3]^[2] As the nerve continues into the infraorbital canal within the orbital floor of the maxilla, it is accompanied by the infraorbital artery and vein, forming a neurovascular bundle that traverses the bony canal parallel to the maxillary sinus roof. This intimate association underscores the risk of vascular injury during maxillary sinus procedures or orbital reconstructions, where the canal's position just above the sinus demands careful dissection.^[1]^[3]^[2] Emerging from the infraorbital foramen onto the face, the nerve's terminal branches relate to the facial artery, crossing its path to supply the midfacial skin, while within the orbit, via the inferior orbital fissure, it positions near the inferior rectus muscle, influencing periorbital sensory mapping. These relations are vital for facial reconstructive surgery and local anesthesia, where the nerve's superficial emergence allows targeted blocks but requires avoidance of adjacent musculature to prevent motility deficits. The overall bony encasement by the sphenoid, palatine, and maxillary bones along its extracranial course offers structural safeguarding, yet the narrow foramina and fossae amplify the diagnostic importance of CT imaging for assessing compressions or variants.^[1]^[3]^[2]

Branches

Intracranial and ganglionic branches

The maxillary nerve, as the second division of the trigeminal nerve (CN V), issues its initial branches within the intracranial space and the pterygopalatine fossa, primarily providing sensory innervation with an autonomic relay function but lacking any motor components.^[1] These branches include the meningeal branch intracranially and the ganglionic and zygomatic branches within the pterygopalatine fossa, reflecting its role in sensory supply to cranial meninges and facilitation of parasympathetic pathways.^[1] The meningeal branch, also known as the recurrent or middle meningeal nerve, is the smallest and earliest offshoot of the maxillary nerve. It arises within the middle cranial fossa, shortly before the main trunk reaches the foramen rotundum, and re-enters the cranium through small foramina to supply sensory innervation to the dura mater of the middle cranial fossa.^[1] This branch provides no autonomic or motor fibers, focusing solely on meningeal sensation.^[1] The ganglionic branches, typically numbering two to three, emerge from the inferior surface of the maxillary nerve and connect directly to the pterygopalatine ganglion within the pterygopalatine fossa. These branches serve as conduits for postganglionic parasympathetic fibers originating from preganglionic inputs via the greater petrosal nerve (from the facial nerve, CN VII), relaying secretomotor signals to target structures such as the lacrimal gland and nasal mucosa without synapsing sensory fibers from the maxillary nerve itself.^[8] The maxillary nerve contributes no sensory innervation through these branches; instead, they facilitate the autonomic relay, with sensory fibers passing through the ganglion to join subsequent maxillary divisions.^[8] The zygomatic nerve arises from the maxillary nerve within the pterygopalatine fossa. It travels through the inferior orbital fissure to enter the orbit, where it divides into the zygomaticotemporal and zygomaticofacial branches, providing sensory innervation to the skin of the temporal fossa and the prominence of the cheek, respectively.^[1] Additionally, the zygomatic nerve carries postganglionic parasympathetic fibers from the pterygopalatine ganglion to the lacrimal gland via a communicating branch with the lacrimal nerve, underscoring its role in autonomic distribution alongside pure sensory supply.^[1] Like other maxillary branches, it contains no motor elements.^[1]

Pterygopalatine and alveolar branches

The maxillary nerve gives rise to several important branches in the infratemporal fossa and pterygopalatine fossa, providing sensory innervation to the upper dentition, nasal cavity, palate, and associated structures. These branches are purely sensory, carrying general somatic afferent fibers without any motor components.^[1] The posterior superior alveolar nerves, typically numbering two to three, originate from the maxillary nerve in the pterygopalatine fossa and pass through the pterygomaxillary fissure into the infratemporal fossa. These nerves descend along the posterolateral wall of the maxillary sinus, entering the bone through foramina on the infratemporal surface of the maxilla to form the posterior superior alveolar plexus. They supply sensory innervation to the maxillary molars and premolars (except the first and sometimes second premolars), the adjacent buccal gingiva, the maxillary sinus mucosa, and the periosteum of the alveolar bone.^[1]^[9] Upon entering the pterygopalatine fossa, the maxillary nerve communicates with the pterygopalatine ganglion via two ganglionic branches, through which its sensory fibers hitchhike to reach distal structures without synapsing. The resulting branches from the ganglion include the orbital branches, which pass through the inferior orbital fissure to innervate the periorbita, orbital floor mucosa, and portions of the sphenoid and ethmoid sinuses. The posterior nasal branches emerge via the sphenopalatine foramen to supply the nasal mucosa, including the superior and middle conchae (lateral branches) and the nasal septum (medial branches, including the nasopalatine nerve that traverses the incisive canal to reach the anterior hard palate). The pharyngeal branch exits through the palatovaginal canal to provide sensory fibers to the mucosa and glands of the nasopharynx. The palatine branches consist of the greater palatine nerve, which descends through the greater palatine canal to emerge via the greater palatine foramen and innervate the mucosa and glands of the hard palate and adjacent gingiva, and the lesser palatine nerves (usually two), which pass through the lesser palatine foramina to supply the soft palate, tonsils, and uvula.^[1]^[9] The middle superior alveolar nerve is an inconstant branch, arising from the maxillary nerve or its infraorbital continuation within the infraorbital groove or canal. It courses along the lateral wall of the maxillary sinus, contributing to the superior alveolar plexus to provide sensory innervation to the maxillary premolars, the mesiobuccal root of the first molar, the adjacent gingiva, and the sinus mucosa. In cases of its absence, its territory is supplied by the anterior and posterior superior alveolar nerves.^[1]

Infraorbital and facial branches

The infraorbital nerve serves as the primary continuation of the maxillary nerve (CN V2) after it enters the orbit through the inferior orbital fissure and traverses the infraorbital groove and canal.^[1] It emerges onto the face via the infraorbital foramen, located approximately 1 cm inferior to the infraorbital margin, and provides sensory innervation to the skin of the lower eyelid, lateral aspect of the nose, upper lip, and cheek.^[10] This terminal branch carries general somatic afferent fibers from the trigeminal ganglion, ensuring cutaneous sensation over these midfacial regions.^[1] From the infraorbital nerve, two superior labial branches typically arise shortly after its emergence from the foramen, descending along the upper lip to supply sensory fibers to the skin and mucosa of the upper lip as well as the nasal vestibule.^[10] These branches penetrate the orbicularis oris muscle and contribute to the innervation of the labial glands, facilitating sensation in this mobile facial area.^[1] The anterior superior alveolar nerve branches from the infraorbital nerve within the orbital floor or infraorbital canal, descending through a bony canal to reach the anterior maxilla.^[1] It provides sensory supply to the maxillary sinus mucosa, the pulp of the upper incisors and canines, and associated periodontal tissues via the superior dental plexus.^[10] Additionally, the infraorbital nerve gives rise to lateral nasal and palpebral branches that distribute to specific facial structures. The lateral nasal branches (often one or two) extend to the skin of the ala and dorsum of the nose, providing sensation to the lateral nasal region.^[1] The palpebral branches (typically two to three) ascend to innervate the skin and conjunctiva of the lower eyelid, ensuring comprehensive coverage of the inferior orbital rim area.^[10]

Function

Sensory distribution

The maxillary nerve, the second division of the trigeminal nerve (CN V₂), provides general somatic sensory innervation, including touch, pain, and temperature, to the midface and associated structures. This innervation covers a broad territory without involvement in proprioception or fine touch discrimination specific to the nerve itself.^[3]^[2]^[11] In the skin, the maxillary nerve supplies the dermatomes of the lower eyelid, cheek, lateral aspect of the nose, and upper lip, conveying sensations from these midfacial regions. This distribution arises primarily through its terminal branches, ensuring sensory coverage of the prominent facial contours without extending to the forehead or temple, which are innervated by the ophthalmic division (V1). There is minimal overlap with the mandibular division (V3), limited to the lower lip and angle of the jaw.^[3]^[2]^[11] Within the oral cavity, the nerve innervates the upper teeth from molars to incisors, along with the overlying gingiva, and the mucosa of the hard and soft palate, supporting sensations critical for mastication and oral health. Additionally, it supplies the mucosa of the maxillary sinus, contributing to the detection of pressure changes or inflammation in this paranasal structure.^[3]^[2]^[11] The maxillary nerve also provides sensory input to the nasal and pharyngeal regions, including the lateral wall and septum of the nasal cavity, the superior and middle nasal conchae, and the mucosa of the nasopharynx. This innervation facilitates the sensing of irritants, airflow, and potential pathologies in these areas, with extension to the sphenoid sinus for mucosal protection.^[3]^[2]^[11]^[12]

Autonomic associations

The maxillary nerve, primarily a sensory branch of the trigeminal nerve (cranial nerve V), serves as a conduit for autonomic fibers without synapsing in its own course, relaying parasympathetic and sympathetic inputs to target structures in the head and neck.^[1] These autonomic associations occur mainly through its connections with the pterygopalatine ganglion, where preganglionic parasympathetic fibers synapse and postganglionic sympathetic fibers pass through to hitchhike on the nerve's branches.^[8] Parasympathetic innervation to the maxillary nerve arises from preganglionic fibers originating in the superior salivatory nucleus of the pons, traveling via the nervus intermedius and greater petrosal nerve (a branch of the facial nerve, cranial nerve VII) before joining the deep petrosal nerve to form the vidian nerve.^[8] These fibers enter the pterygopalatine ganglion, where they synapse, and the resulting postganglionic parasympathetic fibers distribute via ganglionic branches of the maxillary nerve to innervate the lacrimal gland, glands of the nasal and pharyngeal mucosa, and palatal mucosa.^[1] Functionally, this pathway promotes secretomotor activity, including lacrimal secretion for tear production and glandular secretion of mucus in the nasal and pharyngeal regions, while also inducing vasodilation to support mucosal hydration and glandular function.^[8] Sympathetic innervation involves postganglionic fibers from the superior cervical ganglion, which originate from preganglionic neurons in the intermediolateral cell column at spinal levels T1-T2.^[8] These postganglionic fibers reach the pterygopalatine ganglion via the deep petrosal nerve (carrying sympathetic input from the carotid plexus) and the vidian nerve, passing through the ganglion without synapsing before joining branches of the maxillary nerve, such as the zygomatic and infraorbital nerves.^[1] No preganglionic sympathetic fibers travel directly on the maxillary nerve; all relay occurs at peripheral ganglia like the superior cervical.^[8] These fibers provide vasomotor control, primarily vasoconstriction, to the blood vessels in the nasal and pharyngeal mucosa, lacrimal gland, and associated structures, helping regulate blood flow and glandular activity.^[13]

Clinical significance

Local anesthesia and procedures

The maxillary nerve and its branches are commonly targeted for local anesthesia in dental and maxillofacial procedures to achieve profound analgesia in the midface region. Techniques for blocking these structures provide effective anesthesia for extractions, endodontic treatments, and surgical interventions, minimizing the need for general anesthesia. Common agents include lidocaine (2% with 1:100,000 epinephrine) for shorter procedures and bupivacaine (0.5%) for prolonged postoperative pain control, with typical volumes ranging from 0.9 to 1.8 mL per injection site to avoid systemic toxicity.^[14] Complications such as hematoma, due to proximity to vascular structures like the infraorbital artery, or transient paresthesia can occur, with risks mitigated by aspiration and slow injection.^[15] The infraorbital nerve block targets the terminal branch of the maxillary nerve at the infraorbital foramen, providing anesthesia to the lower eyelid, lateral nose, upper lip, and maxillary gingiva and teeth. This technique is indicated for midface procedures such as laceration repairs, facial surgeries, or diagnostic nerve testing. Performed extraorally or intraorally, the needle is advanced to contact the foramen after palpation below the orbital rim, followed by deposition of anesthetic solution. Onset occurs within 3-5 minutes, lasting 1-3 hours with lidocaine.^[16] The posterior superior alveolar (PSA) block anesthetizes the posterior superior alveolar branches of the maxillary nerve, supplying the mesiobuccal root of the first molar and all maxillary molars, ideal for upper molar extractions or restorative work in dentistry. Administered intraorally in a semisupine position, the syringe is aligned parallel to the maxillary occlusal plane, with the needle inserted at the mucobuccal fold over the second or third molar and advanced to contact bone at a 45-degree angle before aspiration and injection of 0.9-1.8 mL of anesthetic. This method achieves pulpal anesthesia in 85-90% of cases, with failure risks from accessory innervation.^[17]^[18] Maxillary nerve blocks, less common due to their invasiveness, provide comprehensive hemi-maxillary anesthesia by targeting the main trunk in the pterygopalatine fossa, used for extensive procedures like Le Fort fracture repairs or cleft palate surgeries. Access is typically via the greater palatine canal intraorally, where a needle is inserted through the foramen and advanced 3-4 cm superiorly to deposit 1.8-3.6 mL of anesthetic, or extraorally using ultrasound guidance for precision in modern variants. This approach, first conceptualized in 19th-century dental texts with cocaine by surgeons like Halsted and Hall in 1885, offers dense block but carries higher risks of intravascular injection or diplopia from pterygopalatine spread.^[19]^[20]^[21]

Pathologies and disorders

The maxillary nerve, as the second division (V2) of the trigeminal nerve, can be affected by trigeminal neuralgia, characterized by paroxysmal, electric shock-like pain in the midfacial region, including the cheek, upper lip, and nasal area.^[22] This condition often involves the V2 distribution unilaterally, with attacks triggered by innocuous stimuli such as touching the face, chewing, or cold air, lasting seconds to minutes and potentially recurring multiple times daily.^[23] Initial treatment typically involves anticonvulsants like carbamazepine, which reduces neuronal hyperexcitability and provides relief in most cases, though refractory instances may require surgical interventions such as microvascular decompression.^[22] Maxillary sinusitis can cause referred pain along the maxillary nerve's alveolar branches, mimicking dental pathology with symptoms of aching in the upper teeth, cheek tenderness, and pressure over the maxillary region.^[24] Inflammation or infection in the maxillary sinus may compress adjacent neural structures, leading to neuropathic-like pain that radiates to the midface without direct sinus drainage issues.^[25] Diagnosis relies on computed tomography (CT) imaging to visualize mucosal thickening, air-fluid levels, or bony erosion in the sinus, distinguishing it from primary neural disorders.^[24] Trauma to the maxillary nerve commonly occurs in zygomaticomaxillary complex fractures, resulting in neuropraxia of the infraorbital branch with symptoms of numbness, paresthesia, or dysesthesia in the upper lip, cheek, and gingival areas.^[26] These injuries often stem from high-impact blunt force, causing temporary conduction block without axonal disruption, and recovery may take weeks to months depending on the extent of edema or compression.^[27] Iatrogenic damage during endoscopic sinus surgery can also injure the infraorbital nerve, particularly if anatomical variants like nerve protrusion into the sinus are not identified preoperatively, leading to postoperative hypoesthesia or chronic pain.^[28] Tumors such as schwannomas or metastatic lesions can compress the maxillary nerve at the foramen rotundum, producing progressive sensory deficits, facial pain, or mass effect symptoms like proptosis if extending into adjacent spaces.^[29] Schwannomas typically arise from Schwann cells along the nerve sheath, presenting as well-circumscribed, enhancing masses on magnetic resonance imaging (MRI) with T2 hyperintensity and possible foraminal widening.^[29] Metastases, often from head and neck primaries, spread perineurally through the foramen rotundum into the pterygopalatine fossa, appearing as irregular nerve enlargement and enhancement on contrast-enhanced MRI, guiding biopsy or resection planning.^[30] Herpetic neuralgia involving the V2 distribution arises from varicella-zoster virus reactivation (shingles) along the maxillary branch, causing initial vesicular rash followed by persistent burning pain in the midface, upper lip, and intraoral mucosa.^[31] Post-viral complications include allodynia and hyperalgesia in the affected dermatome, more common in immunocompromised individuals or those over 50.^[32] Early antiviral therapy with acyclovir or valacyclovir within 72 hours of rash onset reduces viral replication and lowers the risk of prolonged neuralgia, supplemented by gabapentinoids for neuropathic pain management.^[31] Rare disorders include idiopathic trigeminal sensory neuropathy affecting the maxillary division, presenting with isolated, transient numbness or paresthesia in the V2 territory without identifiable cause, often resolving spontaneously within months.^[33]

References

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### Anatomical Relations of the Maxillary Nerve
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Figure 1. The maxillary nerve – origin, branches and their course....
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Technique: Simple and safe PSA nerve block The patient is made to lie down in semisupine position below operators elbow level. As shown in Figure 1.
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