NERVE

Presented By- Richa Bhosale

I MDS, Department Of Periodontics
 CONTENTS

Introduction
Origin
Nuclei of the nerve
Trigeminal ganglion
Course of the nerve
Divisions of the trigeminal nerve
• Opthalmic nerve
• Maxillary nerve
• Mandibular nerve
Applied aspects
12 Pairs of Cranial Nerves

Trigeminal (V)
 Classification of Cranial Nerves
Sensory
I. Olfactory
II. Optic
VII Vesibulocochlear

Motor
III Occulomotor
IV Trochlear
VI Abducent
XI Accessory
XII Hypoglossal

Mixed
V Trigeminal
VII Facial
IX Glossopharyngeal
X Vagus
 The Trigeminal Nerve

Fifth cranial nerve (CN V)

Largest cranial nerve

Derived from the 1st pharyngeal arch

Attachment to the brain at Pons
 Nuclei of the Trigeminal nerve

General somatic Afferent column Branchial efferent column

(Sensory) (Motor)

a. Innervates 8 muscles derived

a. Spinal Nucleus of V nerve from 1st branchial arch
(pain and temperature)

b. Superior sensory nucleus

(touch pressure)

c. Mesencephalic nucleus
(proprioceptive & mechanoreceptive
impulses)
 The Trigeminal Ganglion
(Semilunar Ganglion /Gasserion Ganglion)
Located at the apex of the petrous temporal bone

It is crescent/semilunar in shape

Located in a cave like depression called Meckel’s cave/trigeminal cave

Contains cell bodies of all primary sensory neurons

From the ganglion emerges a large Sensory root and inferiorly passes a small
Motor root
Sensory root fibres enter the concave portion of the crescent and 3
sensory divisions of trigeminal nerve exit from the convexity.

It is attached to pons at its junction to with the middle cerebellar

peduncle
Sensory root divides into :

i. Ophthalmic nerve (V1) - It travels anteriorly in lateral wall of cavernous

sinus to medial part of superior orbital fissure and exits the skull into the
orbit.

ii. Maxillary division (V2) - It travels anteriorly and downwards to exit

cranium, through foramen rotundum into upper portion of
pterygopalatine fossa.

iii. Mandibular division (V3) - It travels almost directly downwards to exit

the skull, along with the motor root, through foramen ovale. It later
forms one nerve trunk, then enter infratemporal fossa.
Motor root arises separately from sensory root.

Originates in main nucleus with pons and medulla oblongata.

Its fibres travel along with but seperately from the sensory root to the
semilunar ganglion/gasserian ganglion.

The motor root passes in a lateral and inferior direction under the ganglion
towards foramen ovale.

Motor fibres supply the following muscles:

1. Masticatory muscles—temporalis, masseter, medial pterygoid

and lateral pterygoid.
2. Mylohyoid.
3. Anterior belly of digastric.
4. Tensor tympani.
5. Tensor veli palatini
 The Ophthalmic division (V1)

 It is the superior and smallest division

 Completely sensory

 Passes anteriorly through lateral wall of cavernous sinus. It

divides into three branches:
i. Frontal
ii. Nasociliary
iii. Lacrimal.

 All these branches pass through superior orbital fissure into

the orbit
 Frontal Nerve
Largest branch

Passes forwards above levator palpebrae superioris

just below frontal bone.

Divides into two branches

Supraorbital Supratrochlear

(larger & lateral) (smaller & medial)

-Upper eyelid - frontal air sinuses

-Conjuctiva - forehead

-lower part of forehead - scalp till vertex

 Nasociliary Nerve
Intermediate in size between frontal and lacrimal nerve
Passes superior orbital fissure medially
Divides into:
Anterior Ethmoidal
 Middle and anterior ethmoidal sinuses
 Anterior aspect of nose and
 Tip of nose.

Posterior Ethmoidal
 Sphenoidal air sinus
 Posterior ethmoidal air sinus

Long Ciliary
 Sensory to eyeball

Infratrochlear
 Both eyelids
 Side of the nose
 Lacrimal sac
Branch to Ciliary ganglion
 Lacrimal Nerve
Smallest among the branches of ophthalmic nerve

Passes laterally through superior orbital fissure

Supplies : lacrimal gland and a small area of adjacent skin and conjunctiva.

Receives postganglionic parasympathetic fibres from pterygopalatine

ganglion which enters orbit with Zygomatic branch of maxillary nerve
 The Maxillary division (V2)
Intermediate in size between the ophthalmic and mandibular division

Purely sensory

Originates from
Trigeminal ganglion in middle cranial fossa

Gives off meningeal branch in middle cranial fossa

Runs forwards through lower part of lateral wall of cavernous sinus

Directed through the foramen rotundum into the uppermost part of

pterygopalatine fossa

short course from pterygopalatine fossa to inferior orbital fissure

gives off main branches in pterygopalatine fossa, posterior superior alveolar

nerve and zygomatic branches.
 enters the orbit through inferior orbital fissure.

occupies the infraorbital groove and becomes infraorbital nerve which courses
anteriorly into the infraorbital canal

emerges on anterior surface of face through infraorbital foramen where it divides into its
terminal branches
 Branches

1) Within cranial cavity-Meningeal branch

i. Travels with middle meningeal artery
ii. Provides sensory innervation to dura mater of anterior half of middle
cranial fossa.

2) In pterygopalatine Fossa
i. Pterygopalatine nerves
ii. Zygomatic nerves
iii. Posterior-superior-alveolar nerve.

3) In the Infraorbital Canal.

i. Middle superior alveolar nerve.
ii. Anterior superior alveolar nerve.

4) Branches on the face

i. Inferior palpebral
ii. External nasal
iii. Superior labial
 Pterygopalatine nerves
 Two short nerves.
 Pass through the ganglion into its branches.
 Serve as a communication between pterygopalatine ganglion and maxillary nerve.

Branch into:

Orbital Palatine
Supply periosteum a. Greater palatine
of orbit nerves
(anterior palatine
nerves)
b. Lesser palatine
Nasal
nerves
i. Nasopalatine
(middle and
(long sphenopalatine)
posterior palatine
nerves)
ii. Posterior superior
 Roof of the mouth,
lateral nasal nerves Pharyngeal
Soft palate, tonsils 
(short sphenopalatine Small nerve
nerves supplies mucous
membrane of
 Supplies palate around nasopharynx
anterior teeth
Naso-palatine nerve block

Greater palatine nerve block

 Zygomatic nerves
Enters the orbit through inferior orbital fissure.

Enters zygomatic bone and divides into two branches

Divides into two branches

i. Zygomaticotemporal nerve
 It supplies skin above zygomatic arch (skin of side of forehead or the
“hairless” skin of temple).

ii. Zygomaticofacial nerve

 It perforates the facial surface of zygomatic bone and supplies skin
over the bone (skin over the prominence of cheek.)
 Posterior Superior Alveolar Nerves

These nerves are 2-3 in number

Descend from the main trunk of the maxillary nerve in the

pterygopalatine fossa

Passes downwards through the pterygopalatine fossa and

reach the posterior surface of maxilla (or infratemporal surface of
maxilla)
One branch remains external to
bone

Continues downward on
posterior surface of maxilla

Provides sensory innervation to

buccal gingiva in maxillary molar
region

Other branch enters maxilla through

the posterior or posterolateral wall of
maxillary sinus

Provides sensory innervation to

mucous membrane of sinus,alveoli,
periodontal ligaments and pulpal tissues
of maxillary molars

With the exception of (25%) patients of

mesiobuccal root of first molar
 Nerves in the infraorbital canal
While in infraorbital groove and canal the maxillary division is known as
infraorbital nerve.

It passes forwards along the floor of orbit, sinks into a groove then enters a
canal and emerges on the face through infraorbital foramen.

It gives multiple small branches through orbital plate of maxilla to roof of

maxillary sinus.

In the infraorbital groove it gives Middle Superior Alveolar nerve

In the infraorbital canal it gives the Anterior Superior Alveolar nerve

 Middle Superior Alveolar Nerve

Supplies - Adjacent mucosa of maxillary sinus

Two premolars
Mesiobuccal root of first molar
Periodontal tissues
Buccal soft tissue and bone in premolar region
 Anterior Superior Alveolar Nerve
Relatively large branch

Innervates

Central incisors
Lateral incisors
Canines
Periodontal tissue,buccal bone, gingiva of same teeth

In patients where Middle Superior Alveolar nerve is absent, the Anterior
Superior Alveolar nerve plays the role of MSA nerve

The innervation of roots of all teeth, bone and periodontal structures are
derived from terminal branches of larger nerves.

These nerves make network; termed as dental plexus.

The superior dental plexus- Composed of small nerve fibres from the three
superior alveolar nerves.

Nerves emerging from these plexus:

Dental nerves

Interdental branches

Inter-radicular branches
 Branches on the Face

Infraorbital nerve emerges on the face through infra-orbital

foramen

Divides into its terminal branches

i. Inferior palpebral - Supplies skin of lower eyelid,both

surfaces of conjunctiva.

ii. External nasal/lateral nasal - skin on lateral aspect of nose.

iii. Superior labial - Skin and mucous membrane of whole of

upper lip
Inferior palpebral nerve
Lateral nasal nerve
Superior labial nerve
 NERVE

Presented By- Richa Bhosale

I MDS, Department Of Periodontics
 The Mandibular Division (V3)
Mandibular nerve is the nerve of first (mandibular) branchial arch.

It is the largest branch of trigeminal nerve.

It is a mixed nerve

Sensory Motor root

root
Two roots emerge separately through the
foramen ovale

Small motor root lies medial to sensory root.

Unite just outside foramen ovale, and form

main trunk of mandibular nerve.
*It resembles the “cat o’ nine tails” in appearance

The branches are

i. Small anterior trunk—motor

ii. Large posterior trunk—sensory

It gives branches in three areas:

i. From undivided nerve

ii. From anterior trunk

iii. From posterior trunk.

Branches of the Trigeminal nerve
 From the undivided trunk
There are two branches:

a) Meningeal branch – (nervus spinosus)

 Passes upwards and re-enters the cranium through foramen ovale.

 It supplies:
i. Cartilaginous part of eustachian tube
ii. Middle cranial fossa
iii. dura mater in the posterior half
iv. mastoid air cells
b) Nerve to Medial Pterygoid

 It sinks into the deep surface of muscle.

 supplies –
i. Medial pterygoid
ii. tensor veli palatini
iii. tensor tympani
 From the Anterior Trunk
Significantly smaller than the posterior trunk

The branches provide:

i. Motor innervations to the muscles of mastication

ii. Branches providing motor innervation to respective muscles are:

1. Deep temporal nerves

2. Nerve to masseter—It gives off branch to temporo-mandibular joint.

3. Nerves to lateral pterygoid—one to each head.

4. Buccal Nerve – (long buccal nerve/buccinator nerve)

The trunk reaches the external surface of the muscle by either passing between its
two heads/winding over its upper border

From this point it is known as long buccal nerve.

The only sensory branch of anterior trunk

The only nerve to pass between two heads of lateral pterygoid

At the level of occlusal plane of mandibular
third or second molar, it crosses in front of
anterior border of ramus and enters cheek
through buccinator muscle

*Anaesthesia of buccal nerve is important for

dental procedures, requiring soft tissue
manipulation on buccal surface of mandibular
molars.
 Branches of Posterior Trunk

Primarily sensory, with a small motor component

Branches into the following:

i. Auriculotemporal

ii. Lingual

iii. Inferior-alveolar nerves

 Auriculotemporal Nerve
Branches:

i. Anterior auricular- skin over the helix and tragus of ear.

ii. Superficial temporal- hairy skin over temporal region & scalp

iii. Articular branches- posterior portion of temporomandibular joint

iv. Branches to external auditory meatus and tympanic membrane.

Communications :

i. Communication with facial nerve-provides sensory fibres to the

skin over the areas where facial nerve provides motor innervation.

ii. Communication with otic ganglion- provides sensory, secretory

and vasomotor fibres to parotid gland
Lingual Nerve
passes ↓ medial to lateral pterygoid muscle

Lies between the ramus and the medial pterygoid muscle in the pterygomandibular
space.

Runs anterior and medial to inferior alveolar nerve

continues downwards and forwards, deep to pterygomandibular raphe

reaches the side of the base of tongue, slightly below and behind and medial to
mandibular third molar.

lies just below the mucous membrane in the lateral lingual sulcus.

proceeds anteriorly in the floor of the mouth winding around the submandibular
(Wharton’s) duct

passes laterally, beneath the duct & across the muscles of tongue to the deep surface
of sublingual gland

breaks up into its terminal branches.

Sensory to anterior two-third of the tongue for both general sensation and
gustation (taste) for this region

Joined by chorda tympani, a branch of facial nerve.

Sensory innervation to mucous membrane of floor of mouth and gingiva

on lingual side of mandible.
Inferior alveolar nerve
Largest branch of mandibular division

Enters mandibular canal at the level of mandibular foramen.

Accompanied by inferior alveolar artery and inferior alveolar vein.

The nerve, artery and vein travel anteriorly in mandibular canal torwards
mental foramen
The nerve divides into terminal branches:
i. Incisive nerve—
 remains within the mandibular canal
 Supplies premolars,canines,incisors and asso. Labial gingiva

ii. Mental nerve—emerges through the mental foramen and divides into
branches that innervate:
a. Skin of chin
b. Skin & Mucous membrane of lower lip.
Mylohyoid Nerve

Branches from inferior alveolar nerve prior to its entry into the
mandibular canal.

It runs downwards and forwards in mylohyoid groove on medial surface

of ramus and along the body of mandible

Reaches the mylohyoid muscle.

Mixed nerve

Motor to mylohyoid muscle and anterior belly of digastric.

Sensory fibres for the skin on inferior and anterior surfaces of

mental protruberance.
Examination of the Trigeminal Nerve

Testing sensory supply

Test for corneal reflex 

Testing motor supply

 Applied Anatomy
 Trigeminal Neuralgia

 Herpes Zoster Ophthalmicus

 Wallenberg Syndrome
 Trigeminal neuralgia
Definition:
“Trigeminal neuralgia (TN) is defined as sudden, usually
unilateral, severe, brief, stabbing, lancinating, recurring pain in
the distribution of one or more branches of trigeminal nerve”

John Locke in 1677 gave the first full description with its treatment

Nicholaus Andre in 1756 coined the term ‘Tic Douloureux.(painful

jerking)

John Fothergill in 1773 published detailed description of TN, since then its
also termed as “fothergill’s disease”
 General Characteristics
Incidence - 4 : 100,000 persons.

Age of occurrence- Late middle age (5th or 6th decade)

Sex predilection- female predisposition (58%).

Affliction for sides- right side is noted (60%).

Division of trigeminal nerve involvement

V3 > V2 > V1
Clinical Characteristics

Manifests as a sudden, unilateral, intermittent

paroxysmal, sharp, shooting, lancinating, shock
like pain, elicited by slight touching superficial
‘trigger points’ which radiates from that point.

Pain is usually confined to one division of

trigeminal nerve.

Pain rarely crosses the midline

Pain -short duration, lasts for a few seconds,may recur with variable
frequency.

During an attack, the patient grimaces with pain, clutches his hands over
the affected side of the face.

Paroxysms occur in cycles, each cycle lasting for weeks or months

In extreme cases, the patient will have a motionless face—the ‘frozen or
mask like face’
Sweet Diagnostic criteria (1955)

 Pain is paroxysmal.

Pain may be provoked by light touch to the trigger zones

Pain is unilateral

The clinical sensory examination is normal.

Pain is confined to the trigeminal distribution

 Trigger Zones

i. In V1—the trigger zone usually lies over

the supraorbital ridge.

ii. In V2—skin of the upper lip, sides of the

nose, cheek, on the gums.

iii. In V3
 Most frequently involved branch.
 Trigger points are seen over the lower
lip, teeth or gums of the lower
jaw,chin.
 Tongue is rarely involved.
Diagnosis

Well-taken history with clinical

examination

Response to carbamazepine is universal

in trigeminal neuralgia

MRI scanning or a CT scan-Preoperative

localization of compressive vessels at the
root entry zone is done by MRI scanning

Diagnostic injections of a local

anaesthetic agent into the patient’s trigger
zone should temporarily eliminate all pain.
 Medicinal management
This is the first line approach

Carbamazepine 100 mg three times a day .

Observed over 1 to 5 weeks period until either remission is achieved or

side effects or toxicity are unacceptable.

Tegretol 100 mg 200 mg or 400 mg tabs are available

Drug dosage should be taken at night

Once the pain remission has been achieved, the drug dose should be kept
at maintenance level or withdrawn and restarted if symptoms appear
Other drugs used are

Tab. Phenytoin: Dose—100 mg three times a day.

Tab.Oxcarbazepine—1200 mg/day>

Valproic acid—600 mg/day.

Other less toxic agents:

Baclofen (Lioresal)—10 mg tds

Gabapentin

Lamotrigine

Topiramate
 Surgical Treatments
Peripheral Injections
Long-acting anaesthetic agents—without adrenaline such as bupivacaine with or
without corticosteroids may be injected at the most proximal possible nerve site

Alcohol injections—peripheral branches of trigeminal nerve can be blocked by the

intraoral injection of 95 per cent absolute alcohol in small quantities (0.5 to 2 ml).

Repeated alcohol injections should be avoided

It causes :

local tissue toxicity

inflammation and fibrosis.
 Peripheral Neurectomy (Nerve Avulsion)

Oldest and most effective peripheral nerve destructive technique

Performed most commonly on infraorbital, inferior alveolar-mental nerve

The procedure is carried out under general anaesthesia to ensure successful

avulsion
Cryotherapy or Cryoneurolysis for Peripheral Nerves
Direct applications of cryotherapy probe at –60ºC produces Wallerian
degeneration.

The nerve is exposed as in neurectomy procedure and is frozen with a cryoprobe

(Nitrous oxide probe) for a period of 1-2 minutes followed by 3 minutes thaw

The pain remission follows the procedure.

The procedure is relatively simple.

Peripheral Radiofrequency Neurolysis (Thermocoagulation)
•A radiofrequency electrode that has the capacity to definitely destroy the pain fibres is
used in this procedure.

•Pain remission in 80 per cent of cases with a 20 per cent/year recurrence rate.

Procedure :Topical anaesthesia with mild sedation is used.

The patient is grounded in an electronic circuit and the 22 gauge lesion probe is
positioned adjacent to nerve to be lesioned.

Lesioning is then carried out at 65 to 75ºC for 1 to 2 minutes.

Advantages :Low morbidity in high-risk—elderly patients.

Disadvantages :
Needs specific electronic armamentarium
Reasonable patient cooperation.
 Anaesthesia Protocol
Injection methahexitone—ultrashort-acting barbiturate (Brevital) dose of 1.5 to 2
mg/kg body weight in increments.

Vitals should be monitored throughout.

Procedure—the patient is made to lie on a table with neck well-extended.

3 points of Hartel are marked

 Gasserion ganglion procedure

(i) Glycerol injection

(ii)Thermocoagulation

(iii)Balloon compression.
Herpes Zoster Ophthalmicus (HZO)

Also known as ophthalmic zoster, is shingles involving the eye.

Caused by varicella zoster
Predilection for Nasociliary branch of ophthalmic division

Symptoms include :
 Rash of the forehead with swelling of the eyelid.
Eye pain, eye redness, and light sensitivity.
Tingling along with a fever before appearance of rash.
 Rash transitioning from
papules to vesicles to pustules to scabs 

Complications :
•Vision loss
•Increased pressure within the eye
•Chronic pain
Underlying mechanism involves a reactivation of the varicella zoster
virus within the ophthalmic nerve.

Diagnostic clue- Unilateral distribution of the lesion

Hutchinson's sign: cutaneous involvement
of the tip of the nose, indicating nasociliary
Treatment: nerve involvement.

Antivirals Positive Hutchinson's sign increases the

-acyclovir/valacyclovir (800 mg likelihood of ocular complications
5times/day) Within 3-4 days of onset associated with HZO.

Cool compresses and mechanical

cleansing

Analgesics

Topical antibiotics,lubricants and

steroids to prevent secondary infection
 Wallenberg syndrome (lateral medullary syndrome)
A stroke causes loss of pain-temperature
sensation from one side of the face and the
other side of the body.

 Etiology:
In medulla Ascending  spinothalamic
tract (carries pain-temperature information
from the opposite side of the body) is
adjacent to Ascending spinal tract of the
trigeminal 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.

The result is loss of pain-temperature (but not touch-position) sensation in
a "checkerboard" pattern (ipsilateral face, contralateral body)

Characteristic diagnostic feature

Symptoms :
•decreased pupil size
•drooping eyelid
•decreased sweating
•double vision
•slurred speech
•Diziness
•Dysphagia
Treatment
•Symptomatic treatment
Eg:
 speech and swallowing therapy
 feeding tube
 blood thinners: Heparin or Warfarin
 anti-epileptics: Gabapentin
 Conclusion
Trigeminal nerve,its anatomic course and branches are important from a
dentist’s point of view since any surgical procedure may lead to nerve
injury.

Nerve blocks given for carrying out various dental procedures involves the
branches of trigeminal nerve ,so to avoid complications we should have
knowledge of course and branches of nerve.

Disorders of trigeminal nerve are not rare,hence knowing about it helps in

appropriate diagnosis and treatment planning.
References :
BD Chaurasia’s Human Anatomy

Textbook of Oral Maxillofacial Surgery- Neelima Malik

Handbook Of Local Anaesthesia- Malamed