TRIGEMINAL NERVE

MOUNIKA
1ST YR PG
CONTENTS
 1. Introduction.
 2. Classification of cranial nerves.
 3. Embryology of trigeminal nerve
 4. Nuclei of trigeminal nerve.
 5. Trigeminal Ganglion.
 6.Course and division of trigeminal nerve.
 7. Branches.(ophthalmic, maxillary, mandibular)
 8.Ganglia associated with trigeminal nerve.
 9. Trigeminal nerve examination
 10. Applied anatomy.
 11.Trigeminal nerve rehabilitation
 12. Conclusion.
 13. References.
INTRODUCTION
 The trigeminal, the largest cranial nerve, is the sensory supply
to the face, the major part of the scalp, the teeth, the oral
and nasal cavity, and the motor supply to the masticatory
and some other muscle.

 Nerve: A bundle of fibres that uses chemical and electrical

signals to transmit sensory and motor information from one
body part of the body to another.

 Neurons: These are specialized cells that constitute the

functional units of the nervous system and have a special
property of being able to conduct impulses rapidly from one
part of the body to another
 Elementary structure of a typical neuron
Neuron consists of a cell body also called as soma or perikaryon.
I t gives off a variable number of processes called as neurites.

 They are of two types:

-Dendrites
-Axon
 AXON has following structures from inside to outside:
Axon.

Myelin sheath.

Endoneurium- which is the connective tissue layer.

It separates and encircle each nerve fibre.

Perineurium- it imparts strength to the nerve as well as

resistance to spread of infection.

Epineurium- consists of loose areolar connective tissue.

Contains lymph vessels and blood vessels.
CLASSIFICATION OF CRANIAL NERVES
 Sensory cranial nerves: contain only afferent (sensory) fibers
ⅠOlfactory nerve
ⅡOptic nerve
Ⅷ Vestibulocochlear nerve
 Motor cranial nerves: contain only efferent (motor) fibs
Ⅲ Oculomotor nerve
Ⅳ Trochlear nerve
ⅥAbducent nerve
Ⅺ Accessory nerve
Ⅻ Hypoglossal nerve
 Mixed nerves: contain both sensory and motor fibers
ⅤTrigeminal nerve,
Ⅶ Facial nerve,
ⅨGlossopharyngeal nerve
ⅩVagus nerve
 DEVELOPMENT

Each arch is characterized by its own:

muscular component

 nerve component

 arterial component

 skeletal component

- Trigeminal nerve is derived from 1st pharyngeal arch

 Musculature of the first pharyngeal arch includes:-
Muscles of mastication :
Temporalis
Masseter
Pterygoids
Anterior belly of diagtric
Mylohyoid
Tensor tympani
Tensor palatini
The nerve supply to these muscles is provided by mandibular division of
trigeminal nerve.
NUCLEI OF TRIGEMINAL NERVE

• Spinal nucleus of V
nerve
• Superior sensory nucleus
General somatic of V nerve
afferent column • Mesencephalic nucleus

• Motor nuclei
Branchial
efferent column
Motor Nucleus

 Located at midpontine level

 Medial to main sensory nucleus

 Fibres distribute to muscles of mastication,

mylohyoid, anterior belly of digastric,
tensor tympani, tensor veli palatini.

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 Upper (main) nucleus

 Location – midpons

 Forms dorsal trigeminothalamic tract

 Ascending fibers terminate in this nucleus

 Convey light touch, tactile discrimination,

sense of position and passive movements

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 Mesencephalic nucleus

 True sensory ganglion

 Contains cells that are structurally and

functionally ganglion cells

 Convey impulses from the muscles

innervated by the trigeminal nerve and
the extraocular muscles, as well as from
the periodontal ligament of the teeth
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Spinal nucleus
 Largest nucleus

 Extends caudally from main nucleus to

level C3 of spinal cord

 Forms ventral trigeminothalamic tract

 Conveys pain and temperature

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TRIGEMINAL GANGLION
RELATION OF GANGLION
DIVISIONS OF TRIGEMINAL NERVE

 Ophthalmic nerve
 Maxillary nerve
 Mandibular nerve
OPHTHALMIC NERVE
 SUPERIOR AND SMALLEST DIVISION.

 WHOLLY SENSORY

 ARISES FROM THE ANTERIOMEDIAL END OF TRIGEMINAL GANGLION

 A SENSORY NERVE PASSES THROUGH THE SUPERIOR ORBITAL FISSURE AND

SUPPLIES THE EYEBALL, CONJUNCTIVA, LACHRYMAL GLAND AND SAC, NASAL
MUCOSA, FRONTAL SINUS, EXTERNAL NOSE, UPPER EYELID, FOREHEAD AND
SCALP.
Divisions of ophthalmic nerve

Lacrimal
nerve

Frontal Nasociliary
nerve nerve
Lacrimal nerve
 Smallest of main ophthalmic branches

 Enters the orbit through the lateral part of the superior orbital fissure

 Receives a twing from the zygomaticotemporal branch of maxillary nerve.

Which contains lacrimal secretomotor fibres

 Supplies the lacrimal gland and the adjoining conjunctiva.

Pierces the orbital septum.
Ends in the upper eyelid, where it joins filaments of the facial nerve
Frontal nerve

supraorbital
nerve

Supratrochlear
nerve
 Supratrochlear:

Runs anteromedially, passing above the troclear.

Gives filament to join the infratrochlear.

Supplies – Skin over the lower forehead.

Conjunctiva
Skin of the upper eyelid.

 Supraorbital:

Passes through the supraorbital foramen.

Branches into medial & lateral.

Supplies – Conjunctiva.
Skin of the upper eyelid.
Twigs to pericranium.
Nasociliary nerve

Branches in the orbit

Branches in the nasal cavity

Terminal branches
on the face
1) Branches in the Orbit:

Long root of the cilliary ganglion: It is sensory & passes through the ganglion without
synapsing and supplies the eyeball.

Long ciliary nerve: Supplies the Iris & Cornea.

Posterior ethmoidal nerve: It enters the post.ethmoidal canal & supplies to the mucous
membrane lining of the Post. Etmoidal & Sphenoidal paranasal air cells.

Anterior ethmoid nerve :It divides the upper part of nasal cavity in to 2 sets of anterior nasal
branches
1:- Internal Nasal Branch
- Medial branch
-Lateral branch
2 :- External Nasal Branches
2) Branches in the nasal cavity:
 The branches arising here supply the mucous membrane of the
nasal cavity.
3) Terminal branches on the face:
 They supply sensory nerves to the skin of the medial parts of the
both eyelids, the lacrimal sac. They also supply skin on the bridge
of the nose.
Autonomic ganglion associated

The ciliary ganglion:

Sensory
Motar
Sympathetic root.
MAXILLARY NERVE
Middle of semilunar Pterygopalatine
ganglion fossa

Orbital cavity

Infraorbital
Terminal branches
groove & canal
Divisions of maxillary nerve
In middle
cranial
fossa

In
pterygop- Maxillary Terminal
alatine nerve branches
fossa

In infrorbital
groove and
canal
Branches In middle cranial fossa
MENINGEAL NERVE:
Also known as nervus meningeus
medius.

It lies within the cranium.

It receives a ramus from the internal

carotid sympathetic plexus and
accompanies the middle
meningeal artery to supply the
duramater.
Branches in pterygopalatine fossa

Zygomatic
nerve

Posterior
Pterygopalatine
superior alveolar
nerve
nerve
ZYGOMATIC NERVE

 Starts in the pterygopalatine fossa.

Enters the orbit through the inferior orbital fissure.

Divides into two branches.

Zygomaticcotemporal: supplying sensory innervation to skin on the
side of the forehead.
Zygomaticofacial: supplying the skin on the prominence of the
cheek.
POSTERIOR SUPERIOR ALVEOLAR NERVE

 It begins in the pterygopalatine fossa but divides into 3 branches which

emerge through the pterygomaxillary fissure.

 2 branches enter the posterior wall of the maxilla above the tuberosity &
supply the 3 molar teeth(except the mesiobuccal root of first molar).

 The third branch pierces the buccinator & supplies the adjoining part of the
gingiva & cheek along the buccal side of the upper molar teeth.
PTERYGOPALATINE NERVE

 This nerve turns straight downward after it has left the trunk of the second
division
 The pterygopalatine ganglion is attached to the medial side of the
nerve.

 Branches of pterygopalatine nerve includes those that supply four areas:-

orbit
nose – a) superior posterior nasal
medial
lateral
b) nasopalatine
palate- a) greater (anterior)
b)lesser (middle & posterior)
pharynx
Autonomic ganglion associated

The sphenopalatine ganglion

Branches in infraorbital groove and
canal

Anterior Middle
superior superior
alveolar alveolar
nerve nerve
Middle superior alveolar nerve

• Arise from the nerve in the posterior part of the infraorbital canal

• Runs in infraorbital groove on the lateral wall max sinus

• Supply premolars, gingiva & adjoining part cheek

• Forms a superior dental plexus with anterior and posterior superior alveolar
branches
ANTERIOR SUPERIOR ALVEOLAR NERVE

 Given off just before exiting from the infraorbital

foramen.
 Supplies the incisor and canine teeth.
 Gives off a nasal branch to supply the mucous
membrane of the anterior part of inferior meatus and
nasal floor.
 Communicates with the nasal branches of the
sphenopalatine ganglion.
Terminal branches on face

Inferior
Lateral nasal Superior labial
palpebral
branches branches branches
CLINICAL ASCEPTS

 Maxillary nerve blocks:-

-Infra orbital nerve block

-Posterior superior nerve block
-Nasopalatine nerve block
-Greater palatine nerve block
 Infra orbital nerve block:-

Area anaesthetized:-
Incisors
Cuspids
Premolar
Mesiobuccal root of the first molar
Bony support
Soft tissue
Upper lip
Lower eyelid
Portion of nose on same side
 Posterior Superior Nerve Block:-

Area anesthetized:-
maxillary molars with the exception of mesiobuccal root of 1st molar
buccal alveolar process of maxillary molars
periosteum
connective tissue
mucous membrane
 Nasopalatine nerve block:-

Area anesthetized:-
Anterior portion of hard palate i.e canine to canine

 Greater Palatine nerve block:-

Area anesthetized:-
Posterior portion of the hard palate and overlying
structures upto 1st premolar area on the side injected
MANDIBULAR NERVE
Branches from undivided nerve

Nerve to
Nervus internal
spinosus ptrygoid
muscle
Branches from divided nerve

Anterior division Posterior division

• Branch to external • Auriculotemporal

pterygoid muscle nerve
• Branch to masseter • Lingual nerve
muscle • Inferior alveolar
• Branch to temporal nerve
muscle
• Buccal nerve
Anterior division
Posterior division

The auriculotemporal
nerve
Lingual nerve
Inferior alveolar nerve
AUTONOMIC GANGLION
ASSOCIATED
 Submandibular ganglion
 Otic ganglion
APPLIED ASPECTS

 Mandibular nerve blocks:-

a)Inferior alveolar nerve block

b)Incisive nerve block
c)Mental nerve block
d)Long Buccal nerve block
 Inferior alveolar nerve block:-

Area anesthetised:-
Body of the mandible
inferior portion of the ramus of the mandible.
Mandibular teeth.
Mucous membrane and the underlying tissues
that are anterior to the 1st molar tooth.
 Mental nerve block:-

 Area anesthetised:-
-Buccal mucous membrane anterior to the
mental foramen ie the 2nd premolar region to midline
-skin of lower lip
 Incisive nerve block:-

Area anesthetised:-
-mental+incisive i.e
buccal mucous membrane anterior to the mental foramen ie the 2nd premolar
region to midline
skin of lower lip.
-pulpal nerve fibres to premolar,canine and incisors
 Long buccal nerve block:-

Area anesthetized:-
buccal mucous membrane and mucoperiosteum of mandibular molar region
TRIGEMINAL NERVE EXAMINATION
Clinical examination

Sensory nerve examination

Motor nerve examination
Trigeminal reflexes
APPLIED ANATOMY
 Sensory disturbances in the distribution of TN are
common after facial injury and are due to stretching,
compression or disturbance of the nerve concerned.

 Damage of nasociliary branch = Loss of corneal reflex

 Sensory distribution of TN causes Headache in –

common cold
boils & sinusitis
infection & inflammation of teeth & gums
Eye problems
Trigeminal
nerve
injuries
Neuropraxia First degree No axonal Loss of sensation,rapid recovery

damage,nodemyelination,no (days to weeks), no microneurosurgery

neuroma

Axonotmesis 2nd ,3rd,& 4th Moreaxonal Loss of sensation, slow incomplete

degree damage,demyelination,possible recovery
neuroma (weeks to months), microneurosurgery

Neurotmesis 5th degree Severe axonal damage,epineural Loss of sensation, spontaneous recovery is
discontinuity,neuroma formation unlikely to occur, microneurosurgery.
TRIGEMINAL NEURALGIA:-

 also known as Fothergill’s disease

Tic douloureux (painful jerking)

it is defined as, sudden ,usually ,unilateral ,severe ,brief ,stabbing ,

lancinating , recurring pain in the distribution of one or more
branches of trigeminal nerve.

Mean age: 50 y onwards

Female predominance (male : female = 1:2 ~2:3)
 Pathogenesis of trigeminal neuralgia

 It is usualy idiopathic.

 The probable etiologic factors are:-

Intra cranial tumours

Infections :- granulomatous and non granulomatous infections involving

5th cranial nerve.
post herpetic neural
Demyelinating conditions
Multiple sclerosis
Petrous ridge compression
Intracranial vascular abnormalities
 Clinical characteristics:-

1.sudden
2.unilateral
3.intermittent paroxysmal
4.sharp shooting. lancinating shock like pain elicited by slight touching
5.pain rarely crosses the midline
6.pain is of short duration and last for few seconds to minutes
7.in extreme cases patient has a motionless face called the frozen or
mask like face
8.presence of intra oral or extra oral trigger zones
9.Provocated by obvious stimuli like
Touching face at particular site, Chewing, Speaking, Brushing,
Shaving, Washing the face.

10.The characteristic of the disorder being that the attacks do not

occur during sleep.
TREATMENT:

 Medical treatment
 Surgical treatment:-
Peripheral injections
Peripheral neurectomy
Cryotherapy
Peripheral radiofrequency
Neurolysis (thermo coagulation)
Gasserian ganglion procedures
POST-TRAUMATIC TRIGEMINAL
NEUROPATHY
 Trigeminal neuropathy is most often secondary to trauma, with a
proportion of close to 40% of all cases.
 The most common underlying cause is impacted lower third molar
extraction .
 Likewise, due to the anatomical position of the lingual nerve in
relation to the third molar, the former can be damaged during
manoeuvring to extract the molar.
HERPES ZOSTER OPHTHALMICUS:-
Caused by Varicella zoster

Predilection for nasociliary branch of ophthalmic division of the trigeminal nerve

CLINICAL FEATURES:-

 Cutaneous lesions:-
Rash
Vesicle
Pustule crust permanent scar
 Ocular lesions:-
Eyelid:-
Perorbital pain
Oedema
Hyperasthesia
Conjunctivitis
Scleritis
Corneal scarring
Glaucoma
TREATMENT:-

Acyclovir 800mg 5 times /day within 4 days of onset of rash

Analgesics
Antibiotic ointments
Systemic steroids 60mg/day
Corneal grafting
 Post
herpetic
neuralgia
MENTAL NERVE NUERALGIA

 Due to resorption of lower alveolar ridge, the borders of the denture

flange may compress on the mental nerve, causing pain.

 Similar pain is felt due to narrowing of the foramen.

 Damage to the Auriculotemporal
nerve in the condylar neck causes
VON facial flushing & sweating instead
of salivary response at the meal
FREY’S time

SYNDROME
WALLENBERG SYNDROME:-
 A stroke which causes loss of pain/temperature sensation
from one side of the face and the other side of the body.

ETIOLOGY:-
 In the medulla, the Ascending Spinothalamic Tract (which carries
pain/temperature information from the opposite side of the body) is
adjacent to the Descending Spinal Tract of the fifth nerve (which
carries pain /temperature information from the same side of the
face)
 A stroke cuts off the blood supply to this area destroys both tracts
simultaneously.
 Results in loss of pain/temperature sensation in a unique
“checkerboard” pattern (ipsilateral face, contralateral body)
Characteristic diagnostic feature.
DAMAGE OF TRIGEMINAL NERVE AS
A COMPLICATION OF SURGERY
 CANCER SURGERIES

 THE OPTHALMIC BRANCHES CAN BE INJURED DURING EYE BROW

SURGERIES.

 PARESTHESIAS OF UPPER LIP,GUMS AND TEETH AREA COMMON

COMPLICATION OFTRANSANTRAL PROCEDURES.

 RISK OF DAMAGE TO LINGUAL NERVE IS TO BE ANTICIPATED DURING

PROCEDURES LIKE REMOVAL OF IMPACTED THIRD MOLARS.
CAVERNOUS SINUS SYNDROME
 Multiple cranial neuropathies
 Exophthalmos, ocular motor defects, sensory loss in V1 and / or V2.
 Pupils may be spared or involved.
 causes: bacterial thrombophlebitis
actinomycosis
rhino cerebellar mucormycosis
aspergillosis
tolosa hunt syndrome
neoplasms
vascular lesions
GRADENIGOS SYNDROME

 Petrous bone osteitis due to otitis media

 Characterized by triad of symptoms consisting of
 periorbital unilateral pain related to trigeminal nerve involvement,
 diplopia due to sixth nerve palsy and persistent otorrhea,
 associated with bacterial otitis media with apex involvement of the
petrous part of the temporal bone (petrositis).
RAEDERS PARATRIGEMINAL SYNDROME:
 Oculo sympathetic paresis with pain in distribution of trigeminal
Nerve.
 Pt. with episodic chronic pain
 Pain and headache
Trigeminal hyperesthesia seen in area supplied by post ganglionic fibres.
HYPERAESTHESIA OVER ALL OR PART OF
DISTRIBUTION OF NERVE –

 Causes –
Vascular lesion
Multiple sclerosis
Herpes infection
NEUROTROPHIC KERATITIS
 Occurs due to partial or complete corneal anaesthesia due to loss of sensory
innervation by the trigeminal N.
 There is impaired response to corneal micro trauma as a result of impaired
regeneration and healing of corneal epithelium
 Causes: infections - HSV, VZV, leprosy
traumatic V N injury
ablation of gasserian ganglion
chemical burns
topical anaesthetic abuse,
beta-blockers,
NSIDS
contact lens wear
systemic: DM, stroke, brainstem
haemorrhage, aneurysm
congenital
  Congenital cutaneous naevi on

PORT
face present on the areas
supplied by one or more divisions
of TN

WINE
STAINS
Sturge -weber
syndrome
Malignant Schwannoma of the
Trigeminal Nerve
 Benign schwannoma of the trigeminal nerve
comprises only 0.2% to 0.4% of all intracranial tumours
 and primarily arises in the gasserian ganglion
 (1). Malignant schwannoma of the trigeminal nerve
 is even more rare.
TRIGEMINAL NERVE REHABILITATION
 Researches has focused on supporting these self healing processes
by physical as well as pharmaceutical means. The following and
substances were tested for their ability to support reconstruction and
sustain nerve growth.
 Electro stimulation
 Neurotropic vitamins
 Antioxidants
 Alpha lipoic acid
 Neutrophins(i.e. NGF)
 CONCLUSION:
 Trigeminal nerve, its anatomic course and branches are very important from a
dentist point of view.

 Disorders of Trigeminal nerve are not rare ,knowing about it will help in formulating
appropriate diagnosis and treatment thus achieving the best possible recovery of
Trigeminal nerve function.

 Nerve blocks given for carrying various dental procedures involves the various
branches of Trigeminal nerve, hence to avoid any complications ,one needs to
have a knowledge about the course and branches of the nerve .
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 Handbook of local anaesthesia by stanley malamed
 Textbook of oral and maxillofacial surgery (neelima Anil Malik)
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Thank you