Trigeminal System

The trigeminal system is a complex collection of nerves and nuclei that mediate
functions within the distribution of cranial nerve V.

There are 4 primary nuclei within the trigeminal system: the main (aka principle, chief)
sensory nucleus of V, the spinal nucleus of V, the mesencephalic nucleus of V, and the
motor nucleus of V.

The mesencephalic nucleus is located within the lateral portions of the midbrain and
superior pons.

The main sensory nucleus of V is within the lateral pons, immediately caudal to the
mesencephalic nucleus.

The motor nucleus of V is in the pons, medial to the main sensory nucleus.

The spinal nucleus of V (along with the spinal tract of V) is a long collection of nerve
bodies and fibers. It begins at the junction of the pons and medulla, caudal to the main
sensory nucleus, and stretches to the level of C2 or C3 within the spinal cord.

The trigeminal ganglion (also Gasserian or semilunar ganglion) is within the medial
portion of the medial cranial fossa. It contains cell bodies of sensory neurons.

The large sensory root is the portion of the trigeminal nerve between the trigeminal
ganglion and the brainstem, before CN V branches.

Distal to the trigeminal ganglion, CN V branches into three main divisions: the
ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves.

V2 innervates mucosa of the upper mouth, nose, pharynx, palate and upper teeth, and
cranial dura.

V3 carries sensation from the external auditory meatus and external surface of the
tympanic membrane, mucosa of the cheeks and floor of the mouth, the tongue, and the
cranial dura.

V3 provides the only motor innervation of the trigeminal system.

Neurons within the motor nucleus of V give rise to fibers that join V3 after passing
under the trigeminal ganglion. There are no motor fibers within the trigeminal ganglion.
Muscles innervated by V3: muscles of mastication (masseter, temporalis, medial
pterygoid, and lateral pterygoid), the tensor tympani, tensor veli palatini, mylohyoid,
and the anterior belly of the digastric.

The lateral pterygoid lowers/opens the jaw (mandible) and causes deviation of the
mandible to the opposite side.

Lesion of V3 → flaccid paralysis of muscles of mastication → jaw deviates toward the

lesioned side due to the unopposed action of the intact contralateral lateral pterygoid
muscle.

The tensor tympani maintains tension on the tympanic membrane so it will vibrate in
response to sound. If sound is excessively loud, it contracts enough to hold the tympanic
membrane stiff and prevent excess sound wave transmission.

Lesion of V3 → paralysis of tensor tympani → hypoacusis, since the flaccid tympanic

membrane is unable to transmit sounds. Stapedius, innervated by CN VII, also dampens
loud sounds, but by pulling the stapes off the oval window. Paralysis of stapedius will
lead to hyper acusis, since it has no role in tightening the tympanic membrane.

The tensor veli palatini tenses and stabilizes the soft palate so that the levator veli
palatini (innervated by CN X) can elevate the soft palate.

Lesion of V3 → paralysis of tensor veli palatini → less robust soft palate elevation on the
lesioned side.

Pain and temperature sensation from the face and oral cavity.

Receptors in the periphery transmit signals to cell bodies of first order neurons within
the trigeminal ganglion. First order neurons send axons caudally in the spinal
trigeminal tract and synapse on second order neurons within the spinal trigeminal
nucleus. Note that the spinal trigeminal tract is adjacent to and travels the length of the
spinal trigeminal nucleus.

Second order neurons begin in the spinal trigeminal nucleus. Their axons immediately
decussate, then ascend in the contralateral ventral trigeminothalamic tract. They
synapse in the ventral posteromedial (VPM) nucleus of the thalamus.

Third order neurons in the VPM nucleus of the thalamus project axons through the
posterior limb of the internal capsule to the face area of the somatosensory cortex.
Discriminatory and light touch and pressure sensation from the face and oral cavity.

Receptors in the periphery transmit signals to first order neurons located in the
trigeminal ganglion. The first order neurons synapse with second order neurons in the
primary sensory nucleus.

Second order neurons in the primary sensory nucleus ascend in the ipsilateral dorsal
trigeminothalamic tract to third order neurons in the VPM of the thalamus.

Note that some second order neurons send axons up the contralateral ventral
trigeminothalamic tract.

Third order neurons in the VPM of the thalamus send axons through the posterior limb
of the internal capsule to the face area of the somatosensory cortex.

Proprioceptive neuron cell bodies are located in the mesencephalic nucleus. They send
axons to the motor nucleus of V as well as other cranial nuclei.

Note that the proprioceptive pathway is the only sensory pathway of the trigeminal
system in which the first order neurons are not in the trigeminal ganglion.

Reflexes of the trigeminal system.

The corneal reflex results in protective blinking following stimulation of the cornea or
other structures of the eye.

Pathway: V1 → spinal tract and spinal nucleus of V → bilateral projections to both facial
nuclei (CN VII) → orbicularis oculi. Both eyes blink when one is stimulated.

The tearing reflex (lacrimal) results in bilateral tearing after irritation to one eye.

Pathway: V1 → spinal tract and spinal nucleus of V → bilateral projections to both facial
nuclei (CN VII) → lacrimal glands and tearing of both eyes. Note the overlap with the
corneal reflex.

Tapping the chin of a patient activates the jaw-jerk reflex.

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Pathway: V3 → mesencephalic nucleus of V → motor nucleus of V → masseter.

In the oculocardiac reflex, pressure on the globe results in changes in cardiac rhythm,
most often bradycardia.

Pathway: V1 → primary sensory nucleus of V → motor nucleus of the vagus → vagus

nerve carries parasympathetic stimulation to the heart.