NEW HORIZON DENTAL COLLEGE AND RESEARCH INSTITUTE

DEPARTMENT OF PROSTHODONTICS AND CROWN & BRIDGE

SEMINAR PRESENTATION

TOPIC- TRIGEMINAL NERVE

GUIDED BY- PRESENTED BY-

DR ASHISTARU SAHA DR POOJA AGRAWAL

DR ANUPAM PURWAR

DR TUSHAR TANWANI

DR PRANAY MAHASETH

DR NEHA NAVLANI

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  CONTENT
1. INTRODUCTION
2. CLASSIFICATION OF CRANIAL NERVE
3. EMBRYOLOGY OF TRIGEMINAL NERVE
4. NUCLEI OF TRIGEMINAL NERVE
5. DIVISON – OPHTHALMIC NERVE
MAXILLARY NERVE
MANDIBULAR NERVE
6. ASSOCIATED GANGLIA
7. APPLIED ANATOMY
8. CONCLUSION

 INTRODUCTION

Nerve- A bundle of fibres that uses electrical and chemical signals to transmit sensory and motor
information from one body part to another.

Nervous system-The nervous system is the part of an animal's body that coordinates its actions
and transmits signals to and from different parts of its body.

Nervous system consists of two main parts-

 Central nervous system(CNS)

Peripheral nervous system(PNS)

Nerves that exit from the cranium are called cranial nerves while those exiting from the spinal
cord are called spinal nerves.

Cranial nerves- Cranial nerves are the nerves that emerge directly from the brain.

Twelve pairs of cranial nerves.

Trigeminal nerve is fifth cranial nerve.

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NERVE IN ORDER

Cranial Nerve I - Olfactory

Cranial Nerve II - Optic
Cranial Nerve III - Occulomotor
Cranial Nerve IV - Trochlear
Cranial Nerve V - Trigeminal
Cranial Nerve VI - Abducens
Cranial Nerve VII - Facial
Cranial Nerve VIII- Vestibulocochlear
Cranial Nerve IX - Glossopharyngeal
Cranial Nerve X - Vagus
Cranial Nerve XI - Spinal Accessory
Cranial Nerve XII - Hypoglossal

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  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) fibers

Ⅲ Oculomotor nerve

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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

• EMBRYOLOGY OF THE NERVE

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 • During the development of embryo, the pharyngeal arches appear in the fourth and fifth
week.

• It give rise to six pharyngeal arches, of which the 5th arch disappears.

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:-

1. Muscles of mastication :Temporalis
Masseter
Pterygoids

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2. Anterior belly of diagastric
3. Mylohyoid
4. Tensor tympani
5.Tensor palatini

The nerve supply to these muscles is provided by mandibular division of trigeminal nerve.

Mesenchyme from the 1st arch also contributes to the dermis of the face, hence sensory supply to
the skin of the face is provided by ophthalmic, maxillary and mandibular branches of the
trigeminal nerve.

• Nuclei of trigeminal nerve-

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It has got 4 nuclei :

1) Main sensory nuclei

2) Spinal nuclei SENSORY

3) Mesencephalic nuclei

4) Motor nuclei

• THE TRIGEMINAL GANGLION

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Also known as Gasserian ganglion, or semilunar ganglion, is a sensory ganglion of the trigeminal
nerve that occupies a cavity (Meckel's cave) in the dura mater, covering
the trigeminal impression near the apex of the petrous part of the temporal bone.

• TRIGEMINAL NERVE

• Trigeminal nerve is the largest cranial nerve.

• It is a mixed nerve.

• Composed of a small motor root and a considerably larger sensory root.

• 3 divisons of trigeminal nerve- Ophthalmic (Sensory)

Maxillary (Sensory)

Mandibular (Mixed)

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 • THE OPHTHALMIC DIVISION-

Smallest of all three branches.

Sensory only

Supplies : eyeballs, conjunctiva, lacrimal gland, mucosa of nose and paranasal sinus, skin of
forehead eyelid and nose.

Ophthalmic divison divides into 3 branches-

Lacrimal nerve

Frontal nerve

Nasiciliary nerve

LACRIMAL NERVE

Smallest of three branches.

It supplies sensory innervation to lacrimal gland and conjunctiva.

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FRONTAL NERVE

Largest of three branches.

At about middle of orbit, frontal nerve divides into two branches-

Supraorbital Nerve

Supratrochlear Nerve

• Supraorbital Nerve- Largest branch

It supplies the skin of the upper eyelid, the forehead, and the anterior scalp region to the vertex
of skull.

• Supratrochlear Nerve- Smallest branch.

It supplies skin of upper eyelid and lower medial portion of the forehead.

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Page 12
NASOCILIARY NERVE

In orbit In Nasal cavity In face

Long root Long ciliary Posterior ethmoid Anterior

Of ciliary nerve nerve ethmoid

Ganglion

Internal nasal External nasal

Medial Lateral

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 • MAXILLARY NERVE

Entirely sensory in function.

It gives off branches in four regions-

In middle cranial fossa

In pterygopalatine fossa

In infraorbital groove

Face

CO
URSE- Middle of semilunar ganglion

Lower part of cavernous sinus

Foramen rotundum

Pterygopalatine fossa

Inferior orbital fissure

orbital surface of maxilla

Infraorbital foramen

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 • IN MIDDLE CRANIAL FOSSA-

- Meningeal branch: Travels along the middle meningeal artery and provides sensory innervation
to cranial dura matter.

• IN PTERYGOPALATINE FOSSA

Zygomatic nerve Pterygopalatine Posterior superior

nerves alveolar branches

Zygomaticofacial Orbital

Posterior sup lat nasal

Zygomaticotemporal Nasal

Medial

Palatine

Greater Middle Posterior

palatine palatine palatine

IN INFRAORBITAL GROOVE

Middle superior alveolar Anterior superior alveolar

nerve nerve

Supplies maxillary bicuspids. Supplies labial gingivae

of the incisors and cuspid

teeth.

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 TERMINAL BRANCHES IN FACE

Inferior palpebral Lateral nasal Superior labial

branches branches branches

Supplies skin of lower skin of side of skin and mucous

Eyelid and conjunctiva nose membrane of

upper lip

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 • MANDIBULAR NERVE

• Largest division of trigeminal nerve

• Mixed in nature. It Has a large sensory root and a small motor root.

• The sensory root originates from trigeminal ganglion whereas the motor root originates in
the pons and medulla oblongata.

• The two roots emerge from the cranium separately through the foramen ovale, the motor
root lying medial to sensory. they unite just outside the skull and form the main trunk of
3rd division.

BRANCHES OF THE UNDIVIDED NERVE:

On leaving the foramen ovale the main undivided trunk gives two branches during its 2-3mm
course ie the meningeal branch and the nerve to medial pterygoid

1. THE MENINGEAL BRANCH

Also called as Nervus Spinosus.

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It re-enters the cranium through the foramen spinosum along with the middle meningeal artery to
supply the duramater.

2. NERVE TO MEDIAL PTERYGOID

It is a motor nerve to medial pterygoid muscle

It supplies one or two filaments which passes through otic ganglion to supply tensor tympani and
tensor veli palatini.

BRANCHES FROM ANTERIOR DIVISION:

Provides motor innervation to the muscles of mastication ,sensory innervation to the mucous
membrane of the cheek and buccal mucous membrane of the mandibular molars.

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The anterior division is smaller than the posterior division.It runs forward under the lateral
pterygoid muscle for a short distance and then reaches the external surface of that muscle by
passing between its two heads, from this point it is known as buccal nerve.

Under the lateral pterygoid muscle,it gives off some branches, i.e.
The deep temporal nerve- to the temporal muscle
The masseter nerve- providing motor innervation to masseter muscle
Lateral pterygoid nerve- providing motor innervation the lateral pterygoid muscle

Buccal nerve- This branch supplies sensory fibers to the buccal gingivae about the mandibular
molars and the mucous membrane of the lower part of the buccal vestibule.

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BRANCHES FROM POSTERIOR DIVISON-

Auriculotemporal nerve- It divides into numerous branches, to the tragus of the pinna of the
external ear, to the scalp about ear and as far upward as the vertex of skull.

Branches-

Parotid branches

Articular branches

Auricular branches

Meatal branches

Terminal branches

Lingual nerve- The lingual nerve contributes many sensory fibers to the mucous membrane of
the floor of mouth and gingiva on the lingual surface of the mandible.

Inferior alveolar nerve- Largest branch of the mandibular division.

It divides into two branches at the region of mental foramen-

Mental nerve Incisive nerve

• Before entering into mandibular foramen it gives off mylohyoid branch.

• GANGLIA ASSOCIATED WITH THE TRIGEMINAL NERVE

1.CILLIARY GANGLION

 connected with nasocilliary nerve by ganglionic branches in orbit, non synapsing

 sensory for orbit

2.PTERYGOPALATINE GANGLION:
connected to maxillary nerve in infratemporal fossa
sensory to orbital septum, orbicularis and nasal cavity, maxillary sinus , palate , nasopharynx.

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3. OTIC GANGLION: lies between trunk of mandibular nerve and tensor palatini , nerve to
medial pterygoid passes through but does not synapse in the ganglion.

4.SUBMANDIBULAR GANGLION: related to lingual nerve,rest on hypoglossus .

supplies posterior ganglionic Parasympathetic secretomotor fibres to submandibular and
sublingual gland.

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 • APPLIED ANATOMY -

Trigeminal neuralgia

Trigeminal neuropathy

Herpes zoster ophthalmicus

• 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

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  Female predominance (male : female = 1:2 ~2:3)

 Pathogenesis of trigeminal neuralgia

It is usualy idiopathic.

The probable etiologic factors are:-

Intra cranial tumors:-Traumatic compression of the trigeminal nerve by neoplastic
(cerebellopontine angle tumor) or vascular anomalies eg arteriovenous malformations

Infections :- granulomatous and non granulomatous infections involving 5th cranial nerve.

 General characteristics

Incidence:- seen in about 4 in 100000 persons

Age of occurrence:- 5th to 6th decade

Sex predilection:-female predisposition

Side involved more frequently:-right side

Division of trigeminal nerve involve; most commonly

mandibular > maxillary >ophthalmic

 Clinical characteristics:-

Sudden

Unilateral

intermittent paroxysmal

sharp shooting

lancinating shock like pain elicted by slight touching

presence of intraoral or extraoral trigger points

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  TREATMENT:
 Medical treatment

Carbamazepine and phenytoin are the traditional anticonvulsants given primarily.

The dosage of the drug used initially should be kept small to minimum especially in elderly
patients to avoid nausea, vomiting and gastric irritation.

Dosage should be taken at night so that adequate serum concentration is present early morning.

 Surgical treatment

Peripheral injections

Peripheral neurectomy

Cryotherapy

Peripheral radiofrequency

Neurolysis(thermocoagulation)

Gasserian ganglion procedures

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 • TRIGEMINAL NEUROPATHY

Facial pain resulting from unintentional injury to the trigeminal system from facial trauma, oral
surgery, ear, nose and throat (ENT) surgery, root injury from posterior fossa or skull base
surgery, stroke, etc.

This pain is described as dull, burning, or boring and is usually constant because the injured
nerve spontaneously sends impulses to the brain.

The injured nerve is also hypersensitive to stimulation, so attacks of sharp pain can also be
present. The area which is sensitive to touch and triggers these sharp attacks is the same area
where the pain occurs. Numbness and tingling are also signs of a damaged nerve.

TREATMENT

Trigeminal neuropathic pain is usually a long-term condition. It is unlikely that any treatments
will completely remove the symptoms. Therefore treatment focuses on reducing symptoms and
helping you to manage the condition.

• HERPES ZOSTER OPHTHALMICUS

 Caused by Varicella zoster virus

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
Corneal scarring
Glaucoma

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TREATMENT

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

 Analgesics

 Antibiotic ointments

 Systemic steroids 60mg/day

 Corneal grafting

 CONCLUSION

Trigeminal nerve, its anatomic course and branches are very important from a dentist point of
view as inadvertant surgical procedure may lead to trigeminal nerve injury.

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.

 REFRENCES

Bennnet CR. Monheim’s local anaesthesia and pain control in dental practice. 7th edition.

Chaurasia BD. Human anatomy volume 3. 6th edition.

Snell RS. Clinical anatomy by regions. 8th edition.

Kazi SN. Anatomy.

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