Cranial nerves

Today we will talk about "cranial nerves" there is a table in your textbook
about these cranial nerves, you have to read your textbook.
As a dentist you have to know 5 things about the cranial nerves, these are
the main objectives:
O I want you to distinguish these nerves on the brain model in the lab ok.
Because you're going to be asked about them in the practical exam. When
you hold the brain, you should know that this cranial nerve is number 1 or
2.
OYou have to identify where each nerve emerges from the brain, for
example when I ask you the nerve that arises from midbrain isthe
cranial nerve that arises from the pons in the brain isyou have to know
where each one came from. We will speak about each one in more details.
OYou have to know the skull foramina through which each nerve passes.
For example the trigeminal nerve, where does it come from?
3 foramina:
1.sup.orbital fissure
2.rhotundum
3.ovali.
Another example CN (cranial nerve number 9) the glossopharyngeal:
from the jugular foramen.
OYou have to know the main function of each nerve; the main one, not in
complete details. For example the hypoglossal CN XII is motor to the
tongue.
OThe last thing I want you to know is the complete details about
CN V=the trigeminal nerve, and CN VII=the facial nerve.
these are the main objectives you need to know about the cranial nerves
and those are the main parts I will be asking you about, whether in the lab
or in the theory exam.

Starting with: why do we call them cranial nerves? Because they are
directly arising from the brain not from the spinal cord.
1
26
th
of March
there are 12 PAIRS of nerves this means there are 12 on the right side
and 12 on the left arising directly from the brain, passing through the
cranial foramina in the skull and hence their name.
we consider them as part of the peripheral system.
Cranial nerves are numbered in order as they arise from the brain, from
anterior to posterior with Latin numbers. The first one that appears
anteriorly is called cranial nerve I then posterior to it is IIetc "in Grant's
Atlas picture 9.1"
4The 1
st
one is the olfactory nerve CN I which is the smelling nerve and
it is the most anterior.
4The 2
nd
is the optic nerve CN II.
4The 3rd is the occulomotor nerve CN III: occulo=referring to the
eyeball and motor=movement so it is related to the movement of the eye.
4The 4
th
is the trochlear nerve CN IV: which is the most slender one(
)and the smallest. It also provides the muscles of the eyeball.
4The 5
th
is the trigeminal nerve CN V: the largest one, once it arises it
divides into 3 main branches: ophthalmic, maxillary, mandibular.
4The 6
th
is the abducent nerve CN VI: from "abduction": for the
abduction of the eye. When you move your eye laterally
( )
4The 7
th
is the facial nerve CN VII: providing the muscles of the face
giving all the expressions when you smile and when you're sadC.
2
As you know we have 2 parts of the nervous system :
1
st
the central nervous system which is: the brain and the spinal cord
2
nd
the peripheral nervous system which is: the peripheral nerves distributed throughout
the body and the cranial nerves are part of them.
The smallest is the 4th
The largest is the 5th
4The 8
th
is the vestibulocochlear nerve CN VIII: responsible for the
balance and hearing.
4The 9
th
is the glossopharyngeal nerve CN IX: arises from the lateral part
of medulla oblongata. Glosso: referring to tongue, Pharyngeal: to
pharynx. The function is providing the sensation to the posterior third of
the tongue and to the pharynx.
4The 10
th
is the vagus nerve CN X: passing in along way through your
body to the thorax and abdomen it's mainly providing parasympathetic
innervations; this is in the autonomic nervous system.
4The 11
th
is the accessory nerve CN XI; it has 2 roots: spinal &cranial
roots. The spinal root provides the trapezius and SCM muscles.
4The 12
th
nerve is the hypoglossal nerve CN XII: it has many rootlets just
beside the pyramid of medulla oblongata for movement of the tongue.
"This nerve works very well in people who talk too much"
The Olfactory nerve
++An entirely sensory nerve that carries the special sensation: smelling.
++The olfactory axons emerge from the olfactory epithelium
in the upper part of the nasal cavity.
++ This olfactory epithelium has smell receptors, the axons of these
receptors extend from the olfactory epithelium in the upper part of the
nasal cavity to pass through the cribriform plate of ethmoid which is
perforated.
3
**Both CN VII & VIII
are close to each other and pass through the same foramin:
internal auditory meatus
From the level of superior conchae and above we have a special
lining epithelium where the respiratory epithelium changes to
olfactory epithelium .
dia ydutS "hollA.rD yb denoitnem t'nsaw siht" :
OO rotom si hcihw dna yrosnes si hcihw eziromem ot yaw a si erehT
.htob si hcihw dna
IIX IX X XI IIIV IIV IV V VI III II I
"S rema S dne M evissa Mlia 2 M kela 2 S & ima 22 Mero M"ne
.htob=2 ,rotom=M ,yrosnes=S
:elpmaxe roF S htob si V NC snaem 2 ,yrosnes si I NC eht snaem ima
rotom si IV NC snaem kelaM ,rotom & yrosnes
"We have magnified the picture of cribriform plate of ethmoid from the
sagittal section (in slide#6) you have about 20 perforations in each side in
the cribriform plate of ethmoid so the total is 40."
++ So the axons extend from smell receptors in the olfactory epithelium
passing through these perforations into the inside of the cranial cavity.
++ In the cranial cavity they aggregate together and synapse with other
neurons; other nerves' cell bodies where a dilatation forms, we call it the
olfactory bulb. This bulb is "sleeping" just above the cribriform plate of
ethmoid, it's the region where the 1
st
order axons synapse with the 2
nd
order neurons .
So at first the olfactory neurons emerge from the nasal cavity, through the
cribriform plate of ethmoid to the olfactory bulb, where they synapse with
the 2
nd
order neurons.
++ Now the axons of these neurons (2
nd
order neurons) of the olfactory
bulb extend in a tract, we call it the olfactory tract, all the way inside the
brain to the temporal lobe.
++ In the temporal lobe there is the primary olfactory area, which is the
smell area.
What I want you to know is that the olfactory bulb represents the
synapse area, this means it has the nerves' cell bodies and the tract has the
axons of these neurons(the 2
nd
order neurons) that extend from the bulb to
the temporal lobe inside the brain.
So when conducting the smelling sense, the receptors of the olfactory
epithelium in the upper part of the nasal cavity carry the sensation via
their axons into the cribriform plate ethmoid toward the bulb where they
synapse with the 2
nd
order neurons and the 2
nd
order neurons carry it from
the bulb (cell bodies) in a tract (axons) toward the primary olfactory
(smell) area in the temporal lobe of the brain.
4
The optic tracts are different
from optic nerves, why? Because
there was a crossover (after the
chiasma we call them tracts)
Study aid: "this wasn't mentioned by Dr.Alloh"
OOThere is a way to memorize which is sensory and which is motor
and which is both.
I II III IV V VI VII VIII IX X XI XII
"Samer Send Massive Mail 2 Malek 2 Sami & 22 More Men"
S=sensory, M=motor, 2=both.
For example: Sami means the CN I is sensory, 2 means CN V is both
sensory & motor, Malek means CN VI is motor
This is how I picture it
The optic nerve
OIt's entirely sensory; conducting the vision sense
OThe axons extend from an inner layer of the eyeball called the retina,
where you have the vision receptors rods and cones.
OThese axons extend to form the optic nerves that pass through optic
foramina or canals in the skull. Once they get inside the skull in the
middle cranial fossa, they make the chiasma (crossover). [Chiasma means
x shape and crossover].
5
The optic tracts are different
from optic nerves, why? Because
there was a crossover (after the
chiasma we call them tracts)
Study aid: "this wasn't mentioned by Dr.Alloh"
OOThere is a way to memorize which is sensory and which is motor
and which is both.
I II III IV V VI VII VIII IX X XI XII
"Samer Send Massive Mail 2 Malek 2 Sami & 22 More Men"
S=sensory, M=motor, 2=both.
For example: Sami means the CN I is sensory, 2 means CN V is both
sensory & motor, Malek means CN VI is motor
OFrom the chiasma, other axons extend to form the optic tracts.
O then the optic tracts go to the thalamus, which is a major station for
sensory pathways, and they synapse there in the thalamus and then the 2
nd
order neurons go to the centre of vision in the occipital lobe posteriorly in
the brain sulcus, mainly in the calcarine sulcus(not sure about the spelling)
Retina of the eyeball optic canal to skull chiasma optic tracts
thalamus(synapse) by 2
nd
order neurons to occipital lobe.
ONow, what happens in the crossover?
We expect that the right neurons go to the left side and the left ones go to
the right side. But what's happening actually is that the medial half of the
neurons is the only part crossing over in the optic chiasma while the
lateral half is not, it stays in the same side of the brain.
For example the right optic nerve of the right eyeball has a medial and a
lateral half, the medial crosses over to the left side while the lateral stays
in the right.
6
The optic tracts are different
from optic nerves, why? Because
there was a crossover (after the
chiasma we call them tracts)
Optic disk
4We have 2 fields of vision for each eye :
1-the nasal field medially: (referring to the nasal bone) the things you see
in the medial side
2-the temporal field laterally: (referring to the temporal bone) the things
you see in the lateral side.
The temporal field (the lateral things you see) goes to the medial half of
the optic nerve that crosses over to the opposite side.
The nasal field (the medial things you see) goes to the lateral half of
neurons that don't crossover so it stays on the same side.
For example:
As you see in the previous picture the temporal field of the right eye goes
to the medial half and then it crosses over to the opposite side
(the left).
The nasal field of the same (right) eye goes to the lateral half and because
the lateral neurons don't crossover it stays on the same side (the right).
Clearrr??
1
st
conditionPapilledema
=The optic foramen is covered by 3 layers of meninges: dura, arachnoid
& piamatter.
=The optic nerve, as it's going to the eyeball through the optic foramen,
pulls these layers along with it until it reaches the eyeball, so as it is
passing through, it carries a meningeal sheath: dura, arachnoid,
subarachnoid space containing CSF (cerebrospinal fluid), & pia mater.
So the optic nerve is covered by the meningeal layer and the CSF is going
with the optic nerve all the way to the eyeball.
=now when there is an increased intracranial pressure (increased CSF
pressure) this pressure increases on the optic nerve and reaches the eyeball
in the optic disc "I marked it on the previous picture".
The optic disc is where the optic nerve enters the eyeball. When the
intracranial pressure or CSF pressure increases in the optic disk region,
what happens? There will be swelling. This edematous swelling means
there is papilledema. Papilla referring to optic disc.
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Clinica
l
=So when you put the ophthalmoscope in the eye you will see it as a
bulging or swelling around the optic disc this is because of the pressure of
the CSF on the retina of eyeball this is an indication of an increased
intracranial pressure.
2
nd
conditionVisual Field Defects:
It is when you have difficulties in your vision, resulting from having a
lesion or damage or injury to the vision pathways: optic nerve, optic
chiasma, or optic tract.
Ounilateral blindness: is when you have loss of vision in one eye.
Ohemianopsia: hemi = one half of the eyeball, a = without , nopsia =
vision so it means loss of vision of one field of the eyeball; either the
temporal or the nasal.
the type of defect depends on where the lesion occurs, if it occurs in:
Othe optic nerve unilateral blindness occurs.
For example if the right optic nerve is damaged, complete loss of vision in
the right eye will occur. So when you diagnose the patient, this is how he
sees with normal eyes (referring to upper circles in slide#18)he can see
with the right and left. But if he can't see in one of the eyes for example
the right one, this indicates damage to the right optic nerve. This is called
unilateral blindness whether it's right or left side. okkkkkkay!!!
Othe optic chiasma bitemporal hemianopsia.
=The damage this time occurs at the level of the optic chiasma. Now
which half crosses over in the chiasma?? The medial half! This half
usually takes which field?? The temporal field, so in this case the vision
will be lost in the temporal field of both eyes.
=When you have a cut in the optic chiasma, which half is going to be
cut? The medial one of both eyes: so the medial half can't crossover
because it was cut and lost the connection with the brain. Which field do
we have in the medial half? The temporal field: so we lose the temporal
field of both eyes, and the patient can't see the lateral things; only the
medial ones. This is called bitemporal hemianopsia; bitemporal means
loss of vision in both of the temporal fields, hemianopsia means half of
the vision in one eyeball.
8
OThe optic tract Contra-lateral Homonymous Hemianopsia (THE
MOST COMMON INJURY)

The tract, whether the right or the left one, carries the nasal field
laterally to the same side, and the temporal field medially to the opposite
side. By damage of the tract you will have a distorted image of a complete
half (right or left fields).
For example the right tract got damaged in the right eye, the lateral is
carrying the nasal field (which is the left field of the right eye) "picture in
slide #14", you also have a cut in the medial half of the left side which is
carrying the temporal field of the left eye (which is the left field of the left
eye) so the whole left side (field) has loss of vision.

so the cut in the right optic tract results in a left homonymous
hemianopsia, homonymous means in the same side; left or right. So when
the patient has lost the vision in the left side of the right eye (nasal field)
and the left side of the left eye (temporal field) that means there is a
damage in the right tract. And if he has loss of vision in the right fields,
this means he has loss of vision in the left tract.

"that was how Dr.Alloh had explained it but I will summarize it for
simplicity in the next paragraph. Please follow the picture in slide#14"




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When the right tract is injured the left fields of vision are lost.
When the left tract is injured the right fields of vision are lost.
For example the right tract(which is neurons after chiasma) got damaged, so we
have a cut in the lateral half coming from the same side (right) and a cut in the
medial half coming from the opposite side (left). Now what are the fields that
got damaged? The nasal field of the right eye (considered the left field of the
right eye) & the temporal field of the left eye (the left field of the left eye)
respectively. So when you have damage in the right tract, your left fields of
both right and left eyes are lost.
So when I ask you
- the unilateral blindness results from a damage in the optic nerve.
-the bitemporal hemianopsia results from a damage in the optic chiasma.
-the homonymous hemianopsia results from a damage in the optic tract.
Othese are the important clinical conditions, you have to memorize them:
-the papilledema which is an indication of intracranial pressure.
-the visual defects regarding the optic pathways.
OOOO
OOOO
OThe Oculomotor Nerve
OCN III : from its name it is motor, carrying motor innervations and it
also carries parasympathetic innervations.
OIt emerges from the anterior aspect of the midbrain (midbrain is part of
brain stem)
OOnce it arises it divides into 2 divisions: superior & inferior.
Both branches enter the orbit through superior orbital fissure and they will
be distributed to the muscles of the eyeball.
O We have several muscles in the eyeball mainly the extrinsic ones; CN
III innervates all the muscles that move the eyeball except for 2:
O superior oblique : (that moves the eye inferior and lateral) innervated
by trochlear nerve CN IV.(SO4)
Olateral rectus : (this is the muscle of cheating) innervated by the
abducent nerve CN VI.(LR6)
Owe refer to them in the equation as SO4 & LR6:
SO4 = superior oblique innervated by the fourth cranial nerve.
LR6 = lateral rectus innervated by the sixth cranial nerve.
And all of the remaining muscles of the eyeball are innervated by the
oculomotor nerve.
Introduction to the eye muscles:
OWhen you look at the eye inside the orbit, you will see muscles attached
to it to move it:
10
OSuperior rectus: appears straight; its function is lifting the eye
superiorly. It's when you look upward.
OInferior rectus : opposite to superior rectus; moves the eye inferiorly.
OMedial rectus : moves the eye medially.
OLateral rectus: moves it laterally.
OSuperior oblique: inserted in an oblique way in the posterior half of the
eyeball superiorly; it pulls the eyeball from its superior aspect and moves
it inferiorly.
OInferior oblique: inserted in the posterior half of the eyeball inferiorly; it
pulls the eyeball from its inferior aspect it & moves it superiorly.
OThe last 2 muscles are inserted in the posterior half of the eyeball.
They are inserted in an oblique way from medial to lateral (not straight) so
superior oblique pulls the eyeball infero-laterally and inferior oblique
pulls the eyeball supero-laterally because they are going medially.
these are the 6 extrinsic muscles of the eye, all innervated by the
oculomotor nerve except for SO4 & LR6.
OAlso I want you to add here, the oculomotor nerve provides autonomic
motor innervations to the sphincter pupilli muscle (intrinsic muscle) which
shrinks your pupil.
Oif you were in a place with strong light and then you go to a dark place
you can't see a thing, you stay for a while until your pupil gets dilated and
the vision gets better; this is the dilator pupilli.

Oor vice versa, when you go from a dark place into a lit () place,
your pupil gets smaller. The muscle constricting the pupil is sphincter
puplli .
Othese are the muscles diagnosed by the doctors, when they put light in
your eyes. Why do they put the light? they want to test the function of the
dilator pupilli muscle; if the pupil opens or not. So this is a vital sign; and
why is it a vital sign? Because it is controlled by the autonomic nervous
system.
Nervous system is 2 parts :
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Osomatic: voluntary system, for example movement the skeletal muscles.
Oautonomic: involuntary movement, which is
sympathetic
parasympathetic
OSympathetic: gives you sympathy in dangerous situations( )
hence its name. When you are in a dark room and you want to see more,
the sympathetic innervations work on the dilator pupilli muscle to dilate
the pupil so that more light gets into the eye resulting in better vision
OParasympathetic: it happens during rest, so when you're relaxed in a
fully lit room the parasympathetic works through the oculomotor nerve to
the sphincter pupilli muscle providing constriction of the pupil.
4So the oculomotor nerve provides:
-motor innervations for all the extrinsic muscles (outside the eyeball)
except for SO4 & LR6.
- autonomic (parasympathetic) innervations for one intrinsic muscle
(inside the eyebll): the sphincter pupilli
Trochlear nerve
4CN IV: Emerges from the posterior aspect of midbrain.
4enters through superior orbital fissure to provide innervations for SO4 .
4the smallest cranial nerve
4the main function: motor innervations to the SO4(superior oblique
muscle)which moves the eyeball inferio- laterally (we will speak about
this muscle in more details when we speak about the eyeball and the
orbit).
4Now before we talk about the trigeminal nerve CN V we will talk about
the abducent nerve CN VI.
Abducent nerve
12
4CN VI: a motor nerve for lateral rectus which moves the eyeball
laterally (LR6).
4Emerges from the groove or the junction between the pons and medulla
oblongata.
4passes through superior orbital fissure.
Trigeminal nerve
OCN V: the largest nerve.
O arises from the pons itself.
OIs a xixed nerve having:
a large sensory root: mainly going to: the face and to the teeth.
a small motor root going to:
the muscles of mastication which are 4 muscles
another 4 muscles:
+mylohyoid : the floor of the mouth.
+anterior belly of digastric .
+Tensor of the tympanic membrane: tensor tympany.
+Tensor of the soft palate tensor villi palatini
4So CN V provides motor root for 8 muscles.
4Once it arises it divides into 3 parts:
Ophthalmic V1: {we talked about its story previously in the face
lecture}
4passes to the orbit through superior orbital fissure.
4it is entirely sensory.
-Provides sensations to:
the tip of the nose,
the region of the orbit
the forehead
the anterior half of the scalp
4when the ophthalmic reaches the orbit at that level it gives 3 branches:
Ofrontal: to the frontal bone, divides into 2 branches.
Onasociliary: divides into several branches but terminates into 2 in the
face
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Olacrimal: to the lacrimal gland and the skin there; doesn't divide
those 3 branches in the orbit terminate into 5 branches in the face:
Osupratrochlear
Osupraorbital
Oinfratrochlear
Oexternal nasal: a termination of anterior ethmoidal
Olacrimal
4So what I want you to write:
the ophthalmic gives 3 branches within the orbit:
1-frontal that gives 2 branches: supraorbital & supratrochlear
2- the lacrimal stays the lacrimal
3-nasociliary gives several branches 2 of them in the face:
external nasal & infratrochlear

These are the 5 terminations in the face.
Maxillary V2:
4 Passes through foramen rotundum then goes to the infraorbital foramen
to give the infraorbital nerve.
4It's entirely sensory to the skin of maxilla and the upper teeth.
4Gives mainly:4 3 branches for the upper teeth:
anterior & middle & posterior nerves of superior alveolar
4 3 branches in the face:
Infraorbital & zygomaticotemporal & zygomaticofacial
Mandibular V3:
4 It's the mixed one which carries the whole motor root of trigeminal and
some of the sensory root.
4So all the previous 8 muscles have their motor innervations from
mandibular nerve of trigeminal.
4Passes through foramen ovali as a main trunk (big nerve); once it leaves
foramen ovali it divides into:
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Both coming from frontal branch
Both coming from
nasociliary
Stays undivided
-a small anterior division: gives 3 motor branches and 1 sensory
-a large posterior division: gives 3 sensory branches and 1 motor.
42 branches of the main trunk:
1-a sensory nerve to the meninges: called meningeal branch; gets back to
foramen spinosum or sometimes foramen ovali. Once it passes through
spinosum, it is called nevous spinosus which is a nerve to the meninges, a
sensory one, coming from the main trunk of V3.
2-the 2
nd
branch of the main trunk is a motor nerve to: medial pterygoid &
the 2 tensors: tensor tympani & tensor palatini.
4We said that a small anterior division of the main trunk gives 3 motor
branches and 1 sensory (the total= 4):
3 motor nerves: going to the remaining mastication muscles:
lateral pterygoid & masseter & temporalis
1 sensory to the cheek : called the buccal nerve; when you pinch
someone from his cheek, this is carried by the sensory buccal nerve of
mandibular (anterior division)
4A large posterior division: gives 3 sensory branches and 1 motor (4).
3 sensory:
1-lingual nerve: the most anterior one; gives sensation to the anterior 2/3
of the tongue. Once it leaves the posterior division, it goes deep to the
tongue.
2-inferior alveolar nerve (inferior dental nerve): enters the mandible to the
teeth and gives sensation to the lower teeth.
3-auriculotemporal nerve: sensation to the auricle and temporal region.
Those are the main 3 sensory nerves of posterior division of
mandibular.
1 motor:
Nerve to mylohyoid: a small branch goes to mylohyoid (the floor of the
mouth) and anterior belly of digastric.
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"So the sensation of anterior 2/3 is from the lingual and post 1/3 is from the
glossopharyngeal CN IX and motor innervations from hypoglossal CN XII"

-Ophthalmic: provides sensation to: -Maxillary to:
the tip of the nose, the maxillary region
the region of the orbit zygomatic region
the forehead
the anterior half of the scalb.

-Mandibular to:
lower cheek
mandibular area

You have to read every detail in your book about the trigeminal nerveC
Next lecture we will finish the remaining cranial nerves
Best wishes for everyone.
The END
Forgive me for any mistakes.
Done by: Esra'a Daraghmeh
a big fat thank you lakoll elly befar3'o elmo7adarat 'cause I just found out
that it's really not as easy as it seems not to mention the back pain or the
eyes going out of the skull(anterolaterally) and I don't wanna start with the
lousy records.
Bas kolloh behoon la dof3etna el7elweh.
True words from the heart to my lovely friends who gave the days their
sweetness. If I ever regret anything it is that I didn't get to know you
before.
To my friends :Alaa, leena, buthaina, 3areen, 3obaida, rawan, hiba,
bashayer, Ayat, Deema, Shatha, Ameera, Noora, Manal, Aya, 3abeer,
Leena.k, do7a, Wafaa, Shereen, Huda, w lakol eldof3a
And special salam la sadee8et el3omr Sabreen.
Good luck in mid second & final and don't worry there will always be
another semester.
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