TRIGEMINAL NERVE

Presented by
Dr Harees shabir JR I
Departmant of Pedodontics
contents

1. INTRODUCTION
2. ANATOMY
3. BRANCHES
4. DENTAL PLEXUS
5. APPLIED ANATOMY
6. CONCLUSION
7. RFERENCES
 HUMAN NERVOUS SYSTEM

CENTRAL PERIPHERAL
NERVOUS SYSTEM NERVOUS SYSTEM
BRAIN CRANIAL NERVES

SPINAL CORD SPINAL NERVES

GANGLIA

3
 PERIPHERAL NERVOUS SYSTEM

CRANIAL NERVES SPINAL NERVES

12 PAIRS 31 PAIRS

•Cranial nerves pass through foramina8 CERVICAL

of skull 12 THORACIC
5 LUMBAR
•Spinal nerves leave through 5 SACRAL
intervertebral foramina 1 COCCYGEAL

4
 CRANIAL NERVES

• Ⅰ Olfactory nerve
• Ⅱ Optic nerve
• Ⅲ Occulomotor nerve
• Ⅳ Trochlear nerve
• Ⅴ Trigeminal nerve
• Ⅵ Abducent nerve
• Ⅶ Facial nerve
• Ⅷ Vestibulocochlear nerve
• Ⅸ Glossopharyngeal nerve
• Ⅹ Vagus nerve
• Ⅺ Accessory nerve
5
• Ⅻ Hypoglossal nerve
TRIGEMINAL NERVE

 Fifth /Trifacial nerve

 Largest cranial nerve.
 Mixed nerve.
 Described by Fallopius and again by
Meckel in 1748.
 Name trigeminal was given by Winslow
on account of its three divisions.
 ANATOMY

 Emerges from the

anterolateral surface
of the pons
 Large sensory root
 A small motor root
 Trigeminal Nuclei
The sensory trigeminal nerve nuclei
 Largest of the cranial nerve nuclei.
 Extend through whole of the brainstem.
 The nucleus is divided into three parts
1. The mesencephalic nucleus
2. The chief sensory nucleus (or "pontine nucleus" or "main
sensory nucleus" or "primary nucleus")
3. The spinal trigeminal nucleus
Chaurasia :human anatomy vol3.head and neck ,5th
edition
Mesencephalic nucleus
 Involved with proprioception.

 Receive proprioceptive information from the jaw

 Send projections to the motor trigeminal nucleus to

mediate jaw reflexes.
The principal sensory nucleus
 Chief sensory nucleus
 It gives discriminative sensation of light touch of the face
 Function as Conscious proprioception of the jaw.

 The spinal trigeminal nucleus

 Receives information about deep/crude touch, pain, and temperature from the
ipsilateral face.
 The facial, glossopharyngeal, and vagus nerves also convey pain information from
their areas to the spinal trigeminal nucleus.

Chaurasia :human anatomy vol3.head and neck ,5th

edition
 Motor Nucleus

 It is Ovoid in shape
 It lies in pons
 medial to the principal sensory nucleus
 Trigeminal Ganglion

 Semilunar or Gasserion Ganglion

 Enclosed in a Pouch like recess of
Dura matter known as MECKEL’S
CAVE OR Trigeminal cave.

 The ganglion is in a depression (the

trigeminal depression) on the
anterior surface of the petrous part
of the temporal bone

 The motor root is below and

completely separate from Liebgott.
the The anatomical basis of dentistry. 3 rd

sensory root at this point. edition. Elsevier.

Various Components

 Sensory component

 Branchial Motor component

 Visceral motor component

 BRANCHIAL MOTOR COMPONENT

 Consists of lower motor neurons whose cell bodies are located

in the motor nucleus of the trigeminal nerve in the brainstem.

 These nerves exit the mid-lateral aspect of the pons, course

within the trigeminal nerve, pass through the trigeminal
ganglion, and within the mandibular nerve before branching.

 The muscles innervated-

temporalis, masseter, medial and lateral pterygoids, tensor
veli palatini, tensor tympani, anterior belly of diagastric
and mylohyoid.
VISCERAL MOTOR COMPONENT

 Visceral motor nerves are not a true component of the trigeminal nerve.
 SENSORY COMPONENT
 Branches of trigeminal nerve (CN V):
 Ophthalmic (V1)
 Maxillary (V2)
 Mandibular (V3)
 Ganglions associated with divisions of
trigeminal nerve

 Ophthalmic nerve- ciliary ganglion

 Maxillary nerve – Pterygopalatine ganglion
(Sphenopalatine ganglion)
 Mandibular nerve – otic and submandibular
ganglion
 Ophthalamic Division
 It leaves the middle cranial fossa through the superior
orbital fissure

 Courses within the lateral wall of the cavernous sinus on

its way to the trigeminal ganglion.
 Smallest of 3 divisions
 Purely sensory
Before entering orbit it gives 3 branches:

1. Lacrimal nerve
2. Frontal nerve:
3. Nasociliary nerve
 1. Lacrimal Nerve

Smallest branch
 COURSE: Runs along the
lateral wall of orbit along upper
border of lateral rectus & ends
in Lacrimal Gland

 Supplies
The conjunctiva
Skin of upper eye lid and
Eyebrow-lateral part

Malamed. Handbook of local anesthesia. 5 th edition.

Elsevier
 2. Frontal nerve
 Largest branch.

 Runs forward between , levator

palpebral superioris & periosteum
lining the roof of Orbit

 Gives 2 branches:
 Supra orbital
 Supratrochlear
Supra orbital nerve

Course:

Lies between levator palpebral

superioris & roof of the orbit,
passes through Supra orbital
notch & curves upwards into the
forehead giving 2 branches:
Medial
Lateral

Supplies :
Conjunctiva&upper eyelid
Scalp upto Lambdoid suture
Supra trochlear nerve
 Course:
It runs forward & medially
above the Orbital muscle medial
to supra orbital nerve. It passes
above the Trochlea reaching the
upper margin of orbit.
Supplies:
Lower & medial part of skin of forehead
 Conjunctiva and upper eyelid
3. Nasociliary nerve

 Lies between optic nerve and the lateral rectus

 Runs medially crossing above the optic nerve and
reaches the medial wall of orbit
 Branches of nasocilliary nerve
Long root of cilliary ganglion
Long cilliary nerve
Ethmoidal nerves
Infratrochlear nerve
Ant. Ethmoidal nerve:
Supplies the skin over the lower part of nose

Infra trochlear nerve:

Upper part of nose
The conjunctiva
Lacrimal sac
II. Maxillary Division
 Purely sensory
 2nd division of trigeminal nerve
 Course
 Arises from
trigeminal ganglion
 Leaves middle cranial
fossa through
foramen rotundum
and reaches
pterygopaltine fossa
 Enters orbit through
Inferior orbital fissure
Chaurasia :human anatomy vol3.head and neck ,5th
edition
 BRANCHES

According to origin they are of 4 types

 In Cranial cavity Meningeal branch

 In Pterygopalatine fossa Pterygopalatine N.
Zygomatic N.
Posterior superior Alveolar nerve
 In infra orbital canal Anterior superior Alveolar nerve
Middle superior Alveolar nerve
 In face Inferior Palpebral
Lateral Nasal
Superior labial nerve
MIDDLE MENINGEAL NERVE
(n. meningeus medius; meningeal or dural
branch)

Is given off from the maxillary nerve directly after

its origin
from the semilunar ganglion.

It accompanies the middle meningeal artery and

supplies
the dura mater .

35
In the Pterygopalatine Fossa

1. Zygomatic br:
○ Zygomaticotemporal – skin over the ant. Temporal fossa
region
○ Zygomaticofacial-skin over prominence of zygomatic
bone.
2. Sphenopalatine nerves
○ Orbital branches
○ Nasal branches
○ Palatine branches

○ Orbital branches: periosteum of orbit, sphenoid sinus, post.

ethmoid cells
 Nasal branches
 Posterior superior lateral nasal branch -nasal septum & post. Ethmoidal cells.

 Medial or septal nasal branch: premaxillary region of the hard palate

 Palatine branches
 Greater palatine(anterior palatine)-mucous membrane of posterior hard palate

 Lesser palatine (middle palatine)-soft palate and tonsil

 Posterior palatine -lower posterior nasal septum, and tonsillar area.

3. Posterior superior alveolar nerve

Gingival-buccal gingiva of upper molars

Alveolar region – it innervates the alveoli,
periodontal ligaments and pulpal tissue of
the upper 3rd molar, 2nd molar ,1st molar,
maxillary sinus.( Exception 28 % of patient,
mesiobuccal root of the 1st molar.)
 In Infraorbital canal:
 Middle Superior alveolar nerve: premolars, mesiobuccal
root of 1st molar, maxillary sinus

Anterior superior alveolar nerve: maxillary incisors,

maxilary sinus

On the face:
Inferiorpalpebral-lower eyelid
Lateral nasal-side of the nose
Superior labial-upper lip
 Mandibular division

 Leaves the middle cranial fossa through foramen ovale

 Is the largest of all three branches.
 Formed by union of 2 roots
 Sensory – From lateral part of trigeminal ganglion,
leaves the skull through foramen ovale
 Motor – Passes through foramen ovale,
unites with sensory root below foramen,
from foramen it enters the infratemporal fossa

Chaurasia :human anatomy vol3.head and neck ,5th

edition
 BRANCHES
 From main trunk:
1. Nervus spinosus
2. Nerve to Medial pterygoid
 From Anterior trunk:
1. Buccal nerve
2. Masseteric nerve
3. Deep temporal
4. Nerve to lateral pterygoid
 From Posterior trunk:
1. Auriculo-temporal nerve
2. Lingual nerve
3. Inferior alveolar
 MAIN TRUNK

 Medial pterygoid nerve.

 is a motor nerve to medial pterygoid muscle
 it gives off smalll branches that are motor to the tensor veli palatini and tensor
tympani.

 Nervous spinosus
 arises outside the skull, then passes into the middle cranial fossa to supply the
dura and the mastoid cells.
ANTERIOR TRUNK

 Anterior trunk is smaller then the

posterior trunk
 Runs forward under the lateral
pterygoid muscle for a short distance.
 Under the lateral pterygoid muscle, it
gives off several branches :buccal
nerve, deep temporal, masseter and
lateral pterygoid nerve.
Malamed. Handbook of local anesthesia. 5 th edition.
Elsevier
POSTERIOR TRUNK

 Is primarly sensory with small motor

component.
 It descends for a short distance downward
and medially to the lateral pterygoid muscle
and gives branches.
 Auriculotemporal nerve
 Lingual nerve
 inferior alveolar nerve.
 Auriculotemporal nerve

Run traverses the upper part of the parotid gland and then
crosses the posterior portion of zygomatic arch and divides
into various branches to supply the tragus of the pinna of the
external ear, to the scalp about the ear, and as far as the vertex
of the skull.
Lingual nerve

 It lies between the ramus and the medial

pterygoid muscle in the pterygomandibular
space.

 Is a sensory tract to the anterior two third

of the tongue .

 It provides both general sensation and

gustation for this region.
AREAS OF TONGUE SUPPLIED BY
LINGUAL NERVE

 Ant. 2/3rd of tongue supplied by fibers of

the ordinary sensation of lingual nerve

 Fibers of taste from the part of the sulcus

terminalis excluding the vallate papillae
 INFERIOR ALVEOLAR NERVE
 Largest terminal branch of mandibular nerve

 Mixed nerve, most of the fibers are motor

 The nerve lies deep to the lateral pterygoid muscle.

 Deep to the ramus of the mandible, it is separated from the medial pterygoid by
sphenomandibular ligament.

 In mandibular canal, it gives branches that supply teeth.

Malamed. Handbook of local anesthesia. 5 th edition.

Elsevier
 As it reaches the region of the mental foramen it divides into 2
terminal branches-mental nerve which supplies the skin of chin
and lower lip; incisive nerve supplies the cuspid and the incisor
teeth.

 A mylohyoid branch supplies fibers to the anterior belly of

diagastric muscle.
DENTAL PLEXUS

 Network of nerves

 Terminal branches of larger nerves in the region

 Innervate individual roots of all teeth, bone and periodontal

structures
SUPERIOR DENTAL PLEXUS

 Small nerve fibers from three superior alveolar nerves

1. Anterior-
2. Middle- and
3. Posterior- superior alveolar nerves

INFERIOR DENTAL PLEXUS

 Derived from inferior alveolar nerve and its branches on both sides
 Three types of nerves emerge from these plexuses
1. Dental
2. Interdental and
3. interradicular
APPLIED ANATOMY

Effects of injury or disease-

 causes paralysis of the muscle supplied
 loss of sensation in the area of supply.

Some important features are as follows-

1. If there is paralysis of pterygoid muscle of one side the chin is pushed to
paralyzed side by the muscle of opposite side
2. Loss of sensation in the opthalmic division - Loss of sensation in cornea leaves
cornea unprotected, leading to corneal ulcerations, further leading to blindness
HERPES ZOSTER

 It is a viral infection caused by herpes virus that produces lesions in the cranial or
spinal ganglia.
 Characterized by an eruption of group of vesicles following the course of the
affected nerve.

Neville: Oral & maxillofacial pathology, 2 nd edition

TRIGEMINAL NEURALGIA

 “tic douloureux” is a condition affecting the trigeminal nerve

or fifth cranial nerve

• It is defined as sudden, usually unilateral, severe, brief,

stabbing, lancinating, recurring pain in the distribution of one
or more branches of the Vth cranial nerve.

 Paroxysmal attacks of facial or frontal pain , lasting a few

seconds to less than 2 minutes.

Neville: Oral & maxillofacial pathology, 2 nd edition

 ETIOLOGY:
 Usually idiopathic
 Multiple sclerosis
 Demylination of the nerve
 Post – traumatic neuralgia
 Petrous ridge compression
 Intracranial vascular abnormalities
 Viral etiology
 Intracranial tumours
 CLINICAL
CHARACTERISTICS:
Pain has the following characteristics:
1. Usually confined to one division of trigeminal nerve.
2. Attacks do not occur during sleep
3. Sudden, intense, sharp, superficial, stabbing, or burning in
quality
4. Severe pain intensity
5. Precipitation from trigger areas or by certain daily
activities (eg, eating, talking, washing the face, cleaning
the teeth)
Pain is of short duration, but may recur with variable
frequency.

In extreme cases, the patient will have a motionless face – the

‘frozen or mask like face’.
Common trigger zones include:

Cutaneous Intraoral
Corner of the lips Teeth
Cheek Gingivae
Ala of the nose Tongue
 PRECIPITATING FACTORS
Shaving
Eating
Drinking
Brushing your teeth
Talking
Putting on makeup
Smiling

66
 TREATMENT
PHARMALOGICAL

CARBAMAZEPINE
BACLOFEN
PHENYTOIN
OXCARBAZEPINE
Surgery

The goal of a number of surgical procedures is to either damage or

destroy the part of the trigeminal nerve that's the source of pain

Alcohol injection
Glycerol injection OR Percutaneous Glycerol Rhizotomy (PGR)
Balloon compression Also called as percutaneous balloon
compression of the trigeminal nerve (PBCTN)
Electric current: percutaneous stereotactic radiofrequency
thermal rhizotomy (PSRTR)
Microvascular Decompression (MVD )
Radiation: GAMMA-KNIFE RADIOSURGERY (GKR)
Percutaneous Glycerol
Injection - glycerol is
injected into the space around
the Gasserion ganglion, and
chemically damages the
nervous tissue.

69
Percutaneous Balloon
Compression Rhizotomy -
a balloon is inflated next to
the Gasserion ganglion,
compressing and
mechanically damaging the
nervous tissue.

70
Radiofrequency
Rhizotomy - an electrode
is advanced into the
Gasserion ganglion, and
heated to thermally
damage the nervous tissue.

71
Gamma Knife Radiosurgery focuses cobalt
radiation upon the trigeminal nerve root,
producing a delayed injury to nervous tissue that
is similar to that produced by other percutaneous
rhizotomy techniques.

72
WALLENBERG SYNDROME

 (also called the lateral medullary syndrome) is a classic clinical

demonstration of the anatomy of the fifth nerve.

 A stroke usually affects only one side of the body. If a stroke

causes loss of sensation, the deficit will be lateralized to the
right side or the left side of the body.
 The only exceptions to this rule are certain spinal cord lesions and the medullary
syndromes, of which Wallenberg syndrome is the most famous example.

 In Wallenberg syndrome, a stroke causes loss of pain/temperature sensation

from one side of the face and the other side of the body.

Daniel M.Laskin: Oral & Maxillofacial surgery

Vol.1,1999,
 SPHENOPALATINE NEURALGIA
ETIOLOGY vasodilatation of the internal maxillary artery near the region
of Sphenopalatine Ganglion
•Unilateral paroxysms of intersperse pain in the region of eyes,maxilla,
ear,mastoid base of the nose and beneath the zygoma

•There are no TRIGGER ZONES

•Seen in persons below 40 years

75
• strong male predilection.
Treatment
- Alcohol injection
-prednisolone, ergotamine,
verapamil
- Resection of the ganglion
 AURICULOTEMPORAL SYNDROME
ETIOLOGY

It results from damage to the Auriculotemporal nerve.The

usually syndrome follows some surgical operation .

CLINICAL FEATURES
Flushing and sweating of the involved side of the face along the
distribution of auriculotemporal nerve.
These signs occurs in response to gustatory stimuli.

TREATMENT
Intracranial division of Auriculotemporal nerve
Botulinum toxin injection
Neville: Oral & maxillofacial pathology, 2nd
edition
 CAUSALGIA [COMPLEX REGIONAL PAIN
SYNDROME]
Is a burning pain and paresthesia associated with deformation of nerves
Seen after surgical tooth extraction
TREATMENT
Injection of procaine ,alcohol
Surgical curettage of bone or Resection of nerves

Neville: Oral & maxillofacial pathology, 2 nd edition

78
Intra operative complications:
1. Nerve damage can occur during IAN block (rare).

2. Lingual & mental nerves are at risk during elevation of

mucoperiosteum.

3. Proper flap designs when working on the buccal surface at

mental foramen region.

4. In an atrophic mandible, the incisions should be placed near the

lingual crest to avoid injury to mental nerve.

5. Care of lingual nerve should be taken in mandibular posterior

region since the lingual nerve is in close proximity to the lingual
plate below the crest of the ridge.
CONCLUSION
 Various surgical and non surgical procedures performed by dentists and surgeons
may result in injury to peripheral branches of the TGN.

 Because of highly complex nature of CNS these injuries can lead to significant
changes in the CNS.

 Therefore the dentists must be aware of these neurobiological consequences of

dental procedures and care must be taken to avoid injuries that could create chronic
neuropathic pain syndrome.

80
Refrences

 Malamed. Handbook of local anesthesia. 5 th edition. Elsevier.

 Chaurasia :human anatomy vol3.head and neck ,5th edition
1992,varghese
 Daniel M.Laskin: Oral & Maxillofacial surgery Vol.1,1999,
AITBS (regd)
 Neville: Oral & maxillofacial pathology, 2 nd edition