TRIGEMINAL NERVE

(DENTIST NERVE)

Department of Public Health Dentistry

Guided by :- Presented by :-
Dr. Prateek Jain sir
Dr. Gaurav Aggarwal sir
Ruchika Soni
BDS 3rd year
14/02/2020
 Contents :-

1. INTRODUCTION
2. TRIGEMINAL NUCLEI
3. FUNCTIONAL COMPONENTS
4. COURSE AND DISTRIBUTION
5. TRIGEMINAL GANGLION
6. DIVISIONS OF TRIGEMINAL NERVE
7. APPLIED ANATOMY
8. SUMMARY
9. REFERENCES
INTRODUCTION
 INTRODUCTION

•It is the fifth cranial nerve.

•It is the largest cranial nerve, mixed nerve (sensory & motor)
•It is sensory to – Skin of face
• - Mucosa of cranial viscera
• - Except Base of tongue and pharynx
•It is motor to – Muscles of mastication
• - tensor veli palatini
• - tensor tympanI
• - anterior belly of digastric
• - Mylohyoid
•ORIGIN – Between midbrain and pons
•Trigeminal nerve is derived from 1st pharyngeal arch.
NUCLEI
General somatic afferent
column

Branchial efferent column

 TRIGEMINAL NUCLEI

• A cranial nerve nucleus is a collection of neurons In the

Brain stem that is associated with One or more cranial
nerves.
• Axons carrying Information to and from the cranial nerves
form a synapse at these nuclei.
• Lesions occurring at these nuclei can lead to effects
resembling those seen by the severing of nerves they are
associated with.
• There are 3 sensory and 1 motor nuclei, Arising from the
anterolateral part of pons.
 SENSORY NUCLEI

• MESENCEPHALIC NEURON :- cell body of pseudo-unipolar neuron. It relays

proprioception from muscles of mastication, extraocular muscles, facial muscles. It
is situated in midbrain just lateral to aqueduct.

• PRINCIPAL SENSORY NUCLEUS :- lies in pons lateral to motor nucleus. It

relays touch sensation.

• SPINAL NUCLEUS :- It is the largest nucleus. It extends from caudal end of

principal sensory nucleus in pons to 2nd or 3rd spinal segment. It relays pain and
temperature.
 MOTOR NUCLEUS

• It is located in pons medial to principal sensory nucleus.

• It is derived from first brachial arch.

• It innervates muscles of mastication, tensor tympani and tensor veli

palatini.
Location of trigeminal nuclei
FUNCTIONAL
COMPONENTS
 SENSORY ROOT
• The fibres of the Sensory root arise from the cells of the
trigeminal ganglion. The branches of the unipolar cells of the
trigeminal ganglion are divided into central and peripheral
branches.

• The central branches leave the concave surface to enter the

pons.

• The peripheral branches are grouped to form the ophthalmic and

maxillary nerves and sensory part of the mandibular nerve.
www.dencyclopedia.com

Sensory root
 MOTOR ROOT

•It arises separately from the motor nucleus of pons.

•At the semi lunar ganglion it passes inferolaterally under the ganglion
towards for ovals, through which it leaves the middle cranial fossa along
with the mandibular division.

After it exists the skull, it unites with the sensory root and forms a single
nerve trunk.

It supplies the following muscles:-

Muscles of masticating, mylohyoid, anterior belly of the diagnostic, tensor
tympani, tensor veil Palatini.
TRIGEMINAL
GANGLION
 TRIGEMINAL
GANGLION

Location of trigeminal ganglion

 TRIGEMINAL GANGLION
• The 3 sensory fibres communicate and form an insertion point
which insert into the middle cranial floss and known as Trigeminal
ganglion/ seminar ganglion/ gasserion ganglion.

• Cresentric in shape with convexity anterolaterally.

• Contains cell bodies of psuedo-unipolar neurons.

• Location – lies in the meckel’s cavity in bony fossa at the apex of

petrous part of temporal bone on the floor of middle cranial
fossa, just lateral to posterior part of lateral wall of the
cavernous sinus.
• Size – 1 x 2 cm.

• Coverings – covered by dural pouch = MECKEL’S CAVE

(cavum trigeminale). Cave is lined by pia and arachnoid
matter. Thus the ganglion is bathed in CSF.

• Arterial supply – ganglionic branches of ICA , MMA,

accessory meningeal artery.
DIVISIONS OF
TRIGEMINAL NERVE
• THE 3 MAIN DIVISIONS OF TRIGEMINAL NERVE
ARE –

1. V1 - OPHTHALMIC DIVISION
2. V2 – MAXILLARY DIVISION
3. V3 – MANDIBULAR DIVISION
1. OPHTHALMIC NERVE
• Superior and smallest division.
• Purely sensory.
• Arises from the anteromedial and of Trigeminal ganglion.

• SUPPLIES – eyeballs, conjunctiva, lacrimal gland,mucosa

of nose, paranasal sinuses and skin of forehead, eyelid and
nose.
COURSE -
It arises from the superomedial part of trigeminal
Ganglion,runs forward in lateral wall of cavernous
Sinus and divide into nasociliary, lacrimal and frontal
Nerves just before entering the orbit through SOF.

Near its origin it communicates with the occulomotor,

Trochlear and abducent nerves in lateral wall of
Cavernous sinus.
• DIVISIONS OF OPHTHALMIC NERVE-
 LACRIMAL NERVE

• Smallest Branch.
• Enters the orbit through the narrowest part of the fissure.
• Communicates with Zygomatic branch.
• Enters the lacrimal gland and gives several branches.
• Finally pierces the orbital septum and ends in upper eyelid.
• Supplies lacrimal sac and gland.
 FRONTAL NERVE

• Largest branch.
• Enters the orbit through lateral part of SOF outside
tendinous ring.
• Runs forward between roof of orbit and elevator palpebral
Superioris.

• Divides midway into :- SUPRATROCHLEAR NERVE

SUPRAORBITAL NERVE
 SUPRATROCHLEAR
NERVE
• Smaller nerve
• Medial branch
• Receives communication branches
from infratrochlear nerve.
• Curves around superomedial
margin of orbit.
• Lies b/w frontal is and corrugator
superciliary muscle.
• Supplies median conjunctiva, and
lower part of forehead.
SUPRAORBITAL
NERVE
• Larger nerve
• Lateral branch
• Passes through supraorbital notch.
• Divides in medical and lateral
branches.
• Lies beneath the frontal is muscle.
• Supplies scalp upto vertex,mucous
membrane of frontal sinus.
 NASOCILIARY NERVE

• Intermediate in size.
• Runs more deeply.
• Passes through middle part of SOF within the tendinous ring.
• Runs deeply between Superior oblique and medial rectus.
• It divides into the following branches :-

• BRANCHES IN THE ORBIT - Short ciliary nerve

- Long ciliary nerve
- posterior ethmoidal nerve
- anterior ethmoidal nerve
- infratrochlear nerve
• BRANCHES IN THE NASAL CAVITY :- the branches that arise
here supply the mucous membrane of nasal cavity.

• TERMINAL BRANCHES ON THE FACE :- these branches Supply

• skin of medial part of both eyelids and lacrimal sac
• Skin on the bridge of nose.
1.
SHORT CILIARY NERVE EYEBALL

2.
LONG CILIARY NERVE IRIS & CORNEA

3.
POSTERIOR ETHMOIDAL NERVE POSTERIOR ETHMOIDAL &
SPHENOIDAL SINUS
4. INFRATROCHLEAR NERVE SKIN OF LACRIMAL SAC &
CARUNCLE

5. ANTERIOR ETHMOIDAL NERVE ANTERIOR ETHMOIDAL & FRONTONASAL

In upper part of nasal cavity it further SINUS.
divides into

1. INTERNAL NASAL BRANCHES MEDIAL BRANCHES TO SEPTAL MEMBRANE

LATERAL BRANCHES TO NASAL CONCHAE &
ANTERIOR NASAL WALL

2. EXTERNAL NASAL BRANCHES SKIN ON THE TIP & ALA OF NOSE

2. MAXILLARY NERVE
• Second & intermediate division of Trigeminal nerve.
• Purely sensory

• SUPPLIES :- it supplies Derivatives of maxillary process & frontonasal

process.
• COURSE :- The course of
maxillary nerve before
the foramen rotundum is
the INTRACRANIAL
COURSE.And its course
after emerging from
foramen rotundum is
known as EXTRACRANIAL
COURSE of maxillary
nerve.
•Before entering in the foramen rotundum it gives branch in the middle
cranial fossa I.e. the MIDDLE MENINGEAL BRANCH.

•After leaving foramen rotundum it moves anteriorly in the pterygopalatine

fossa. Here it gives ZYGOMATIC BRANCH, NERVE TO
PTERYGOPALATINE,POSTERIOR SUPERIOR ALVEOLAR NERVE.

•Then it enters infraorbital groove, passes through infraorbital fissure and

in the infraorbital canal it gives 2 branches I.e. ANTERIOR SUPERIOR
ALVEOLAR NERVE & MIDDLE SUPERIOR ALVEOLAR NERVE.

•Now from infraorbital canal it emerges on face & gives 3 branches I.e.
INFERIOR PALPEBRAL BRANCH,LATERAL NASAL BRANCH, SUPERIOR LABIAL
1. MIDDLE MENINGEAL BRANCH DURAMATER OF ANTERIOR & MIDDLE CRANIAL FOSSA

2. ZYGOMATIC NERVE
• ZYGOMATICO FACIAL SKIN OVER PROMINENCES OF CHEEK

• ZYGOMATICO TEMPORAL SKIN OVER ANTERIOR TEMPORAL FOSSA REGION

2. NERVE TO PTERYGOPALATINE
• ORBITAL BRANCH PERIOSTEUM OF ORBIT

• PHARYNGEAL BRANCH NASAL PART OF PHARYNX

• NASAL BRANCH SUPERIOR AND INFERIOR CONCHAE

POSTERIOR ETHMOIDAL SINUS
POSTERIOR PART OF NASAL SEPTUM

• PALATINE BRANCH DIVIDE INTO

a) GREATER PALATINE BRANCH HARD PALATE FROM MESIAL PORTION OF 1ST PREMOLAR
TO DISTAL PORTION OF LAST MOLAR

b) LESSER PALATINE BRANCH SOFT PALATE

 MUCO BUCCAL FOLD
3. POSTERIOR SUPERIOR ALVEOLAR BUCCAL MOLAR REGION
NERVE 1ST 2ND 3RD MOLARS EXCEPT MESIO
BUCCAL ROOT OF 1ST MOLAR

4. ANTERIOR SUPERIOR ALVEOLAR NERVE INCISORS & CANINES

5. MIDDLE SUPERIOR ALVEOLAR NERVE PREMOLAR + MESIO BUCCAL ROOT OF 1ST

MOLAR
6. INFERIOR PALPEBRAL BRANCH SKIN OF LOWER EYELID

7. LATERAL NASAL BRANCH SKIN OF LATERAL WALL OF NOSE

8. SUPERIOR LABIAL BRANCH SKIN AND MUCOUS MEMBRANE OF UPPER

LIP, CHEEK,LABIAL GLANDS
3. MANDIBULAR NERVE
•Third & Largest division
•Mixed

•Made up of two roots – a large sensory root from trigeminal ganglion & emerges out
through foramen ovale and a small motor root from motor nucleus in pons & it unites
with the sensory root just outside the foramen.

•COURSE :- Immediately beyond the junction of two roots the nerve divides into
meningeal branch and nerve to medial pterygoid. Now the main trunk divides into a
small anterior & a large posterior trunk. As it descends from the foramen, the nerve
lies at a distance of 4cm from the surface and a little in front of neck of mandible.
Branches :-
# BRANCHES FROM UNDIVIDED NERVE-

1. MENINGEAL BRANCH OF MANDIBULAR NERVE/ DURAMATER OF MIDDLE CRANIAL FOSSA

NERVOUS SPINOSUS

2. NERVE TO MEDIAL PTERYGOID MEDIAL PTERYGOID MUSCLE THROUGH OTIC GANGLION

# BRANCHES FROM DIVIDED NERVE –

1. ANTERIOR DIVISION –

• BUCCAL NERVE BUCCINATOR MUSCLE

• MASSETERIC NERVE MASSETER MUSCLE
• DEEP TEMPORAL NERVE (2) TEMPORALIS MUSCLE
• NERVE TO LATERAL PTERYGOID (20 LATERAL PTERYGOID MUSCLE
2. POSTERIOR DIVISION-

• AURICULO TEMPORAL NERVE

PAROTID BRANCHES
ARTICULAR BRANCHES
AURICULAR BRANCHES
MEATAL BRANCHES
TERMINAL BRANCHES
SECRETOMOTOR, VASOMOTOR
TMJ
TRAGUS, ROOF OF EAM, UPPER PART OF AURICLE,
TYMPANIC MEMBRANE
MEATUS OF TYMPANIC MEMBRANE
SCALP OVER TEMPORAL REGION

LINGUAL NERVE SENSORY TO ANTERIOR 2/3 OF TONGUE ALONG WITH

SPECIAL SENSATIONS
BRANCHES OF LINGUAL NERVE AND ITS SENSORY TO FLOOR OF MOUTH AND GINGIVA ON
COMMUNICATION :- LINGUAL SIDE OF MANDIBLE

• CHORDA TYMPANI
• COMMUNICATION WITH SUBMANDIBULAR GANGLION
• HYPOGLOSSAL NERVE
• INFERIOR ALVEOLAR NERVE
MENTAL NERVE SKIN OF THE CHIN, SKIN OF LOWER LIP, MUCOUS
INCISIVE BRANCH MEMBRANE
INCISORS & CANINES
MYLOHYOID NERVE
MYLOHYOID MUSCLE & ANTERIOR BELLY OF
DIAGASTRIC
GANGLIA ASSOCIATED
WITH TRIGEMINAL NERVE
• SUBMANDIBULAR GANGLION – Small ovoid body that is suspended from the lingual
nerve above the submandibular salivary gland. The sensory nerves reach the
ganglion through the lingual nerve. They provide secretomotor fibres to the
submandibular & sublingual glands.

• OTIC GANGLION – Flat ovoid body located on the medial side of undivided
nerve. It is Located below the foramen ovale & MMA.

• CILIARY GANGLION – connected with nasociliary nerve by ganglionic branches in

orbit. Non synapsing. Sensory for orbit.

• PTERYGOPALATINE GANGLION- Connected to maxillary nerve in infratemporal

• Fossa. Sensory to orbital septum, orbicularis,nasal cavity,
maxillary Sinus,palate, nasopharynx.
APPLIED ASPECTS
 MAXILLARY NERVE BLOCKS

Block of maxillary nerve through

the greater palatine canal Is a
useful technique To provide profound
anaesthesia In the hemi-maxilla.

GREATER PALATINE FORAMEN

 INFRAORBITAL NERVE BLOCK

A successful infraorbital nerve block

provide anaesthesia for the area b/w
Lower eyelid & upper lip.
When the infraorbital
nerve is anesthetized within
the infraorbital canal, additional structures
desensitized include the ipsilateral maxillary
and premaxillary teeth, and associated alveoli
and gingiva
 MANDIBULAR NERVE BLOCK

• Mandibular nerve block involves blockage of the

auriculotemporal, inferior alveolar, buccal, mental,
incisive, mylohyoid, and lingual nerves. It results in
anesthesia of the following areas –
• Mandibular teeth to midline
• Body of mandible
• Inferior portion of ramus
• Buccal mucoperiosteum
• Anterior 2/3 of tongue
• Floor of mouth
TRIGEMINAL NERVE
INJURIES
 TRIGEMINAL NEURALGIA also known as Fothergill’s disease &
Tic douloureux (painful jerking)

INTRO - It is a paroxysmal, intermittant,excruciating pain

confined to one of the branches of the trigeminal nerve.
Characterised by unilateral affliction, not crossing the
midline, presence of trigger zones, cessation of pain
during sleep.

ETIOLOGY- The etiology is not definitely known. 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 Trigger zones
• Intracranial vascular abnormalities.

• Mean age – 50 yr onwards

• Sex - Female predominance (male : female = 1:2 ~2:3)

• Diagnosis -Based on C/f s & diagnostic test block on the trigger zones.
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
TREATMENT-
1. Carbamazepine(Tegretol) 100 mg od, bd or tid, depending
on the severity or frequency of pain.
2. Injection of 60 to 90% alcohol in the nerve trunk or
ganglion.
3. Peripheral nuerectomy or cryotherapy of the peripheral
trigger zone.
4. Peripheral radiofrequency thermolysis & radiofrequency
thermogangliolysis.
5. Microvascular nerve root decompression procedure. It is a
nuerosurgical procedure wherein the internal vascular
loops of the superior cerebellar artery is made to compess
on the trigeminal nerve root.
 MENTAL NERVE NUERALGIA

• Due to resorption of the lower alveolar ridge, the borders

of the denture flange may compress on the mental nerve,
causing pain.
• Radiologically, the foramen can be seen at the level of the surface
of the ridge.
• Shifting the foramen down is the treatment of choice.
• Similar pain is felt due to narrowing of the foramen.
• Decompession of the nerve by carefully enlargening the foramen
is the treatment of choice.
 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
 TREATMENT:-
Acyclovir 800mg 5 times /day within 4 days of onset of rash
Analgesics
Antibiotic ointments
Systemic steroids 60mg/day
Corneal graftingEyelid:-
• Ocular lesions –
• Perorbital pain
• Oedema
• Hyperasthesia
• Conjunctivitis
• Scleritis
• Corneal scarring
• Glaucoma
 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.
 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, it Causes –
• Vascular lesion
• Multiple sclerosis
• Herpes infection
 PORT WINE STAINS

• Congenital cutaneous naevi on face

present on the areas supplied by
one or more divisions of TN.
 STURGE-WEBER SYNDROME

• Sturge-Weber syndrome (SWS) is a
neurocutaneoussyndrome, characterized by the
association of facial port-wine hemangiomas in
the trigeminal nerve distribution area, with vascular
malformation of the brain (leptomeningeal angioma)
with or without glaucoma
 MALIGNANT SCHWANNOMA OF THE
TRIGEMINAL NERVE

• Benign schwannoma of the trigeminal nerve.

• comprises only 0.2% to 0.4% of all intracranial tumours.
• Primarily arises in the gasserian ganglion.
TRIGEMINAL NERVE
REHABILITATION  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 .
 REFERENCES

• B D chaurasia’s human anatomy, volume III, 6th edition

• Burket’s oral medicine,11th edition
• Handbook of local anaesthesia by stanley malamed
• Textbook of oral and maxillofacial surgery (neelima Anil Malik)
• Neuropathology 2014
THANK YOU