TRIGEMINAL NERVE

(CRANIAL NERVE V)
PRESENTED BY:
HAMZA YOUSAF
USAID YOUSAF
AMNA KHALIL
MAHA AZIZ
RIMSHA AKRAM
 CONTENTS
• INTRODUCTION
• TRIGEMINAL NERVE NUCLEI
• COURSE AND DISTRIBUTION OF THE NERVE
• 3 DIVISIONS OF THE NERVE;
• 1. OPHTHALMIC DIVISION (V1)
• 2. MAXILLARY DIVISION (V2)
• 3. MANDIBULAR DIVISION (V3)
• CLINICALS
 INTRODUCTION
• The trigeminal nerve is the largest cranial
nerve and contains both sensory and motor
fibers.
• It is the principal somatic sensory nerve for
the head (face, teeth, mouth, nasal cavity, and
dura mater of cranial cavity).
• It is a motor nerve to several muscles,
including muscles of mastication.
 TRIGEMINAL NERVE NUCLEI
• MESENCEPHALIC NUCLEUS:
• Composed of a column of unipolar nerve cells situated in the lateral
part of grey matter around cerebral aqueduct. Extends inferiorly
into the pons as far as the main sensory nucleus.
• MAIN SENSORY NUCLEUS:
• Lies in the posterior part of the pons, lateral to motor nucleus.
Continuous below with spinal nucleus.
• MOTOR NUCLEUS:
• Situated in pons medial to main sensory nucleus.
• SPINAL NUCLEUS:
• Continuous superiorly with main sensory nucleus in pons and
extends inferiorly through whole length of medulla oblongata and
into upper part of spinal cord as far as second cervical segment.
TRIGEMINAL NERVE NUCLEI SEEN IN CORONAL SECTION OF PONS
TRIGEMINAL NERVE NUCLEI IN BRAINSTEM
 SENSORY COMPONENT OF TRIGEMINAL
NERVE
• Sensations of pain, temp, touch & pressure from skin of
face & mucous membrane travel along axons whose cell
bodies lie in trigeminal sensory ganglion & their central
processes form large sensory root of trigeminal.
• On entering pons, about half the fibers divide into
ascending and descending branches.
• Ascending branches terminate in main sensory nucleus &
descending branches in spinal nucleus.
• Touch & pressure  main sensory nucleus
• Pain & temp  spinal nucleus
• Fibers from ophthalmic division  inf. Part of spinal
nucleus
• From maxillary division  middle part of spinal nucleus
• From mandibular division  superior part of spinal nucleus
• Proprioceptive impulses from muscles of mastication &
facial + extra ocular muscles are carried by fibers in sensory
root of trigeminal nerve after bypassing trigeminal ganglion
& their origin is mesencephalic nucleus.
• Axons of neurons from spinal and main sensory nuclei &
central processes of cells in mesencephalic nucleus cross
median plane & ascend as trigeminal leminiscus to
terminate on ventral posteromedial nucleus of thalamus.
• They then travel through internal capsule to post central
gyrus (areas 3,1 &2) of cerebral cortex.
 Motor component of Trigeminal Nerve
• Motor nucleus receives corticonuclear fibers from
both cerebral hemispheres, reticular formation, red
nucleus, tectum & medial longitudinal fasciculus. It
also receives fibers from mesencephalic nucleus to
form monosynaptic reflex.
• From motor nucleus, cells give rise to axons that
form motor root of trigeminal & it supplies muscles
of mastication, tensor tympani and tensor veli
palatini, mylohyoid & Ant. Belly of digastric muscle.
 COURSE OF THE NERVE
• The nerve leaves the anterior aspect of pons as small motor
root and large sensory root  passes forward out of posterior
cranial fossa to reach apex of petrous part of temporal bone in
middle cranial fossa  here large sensory root expands to form
tirgeminal ganglion which lies in pouch of dura mater called
trigeminal or meckel cave.
• From anterior border of ganglion  3 divisions arise.
• The ophthalmic nerve(V1) contains only sensory fibers & leaves
skull through superior orbital fissure to enter orbital cavity.
• The maxillary nerve(V2), again only sensory, leaves skull
through foramen rotundum.
• The mandibular nerve(V3) containing both sensory & motor
fibers leaves skull through foramen ovale.
 DISTRIBUTION OF THE NERVE
• OPHTHALMIC DIVISION:
• Forehead and scalp
• Frontal and ethmoidal sinus
• Upper eyelid and its conjunctiva
• Cornea
• Dorsum of the nose
• Lacrimal gland
• MAXILLARY DIVISION:
• Lower eyelid and its conjunctiva
• Cheeks and maxillary sinus
• Nasal cavity and lateral nose
• Upper lip
• Upper molar, incisor and canine teeth and the associated gingiva
• Superior palate
• Lacrimal & nasal glands
• MANDIBULAR DIVISION:
• Sensory supply:
• Mucous membranes and floor of the oral cavity
• External ear
• Lower lip
• Chin
• Anterior 2/3 of the tongue (only general sensation; special taste
sensation supplied by the chorda tympani, a branch of the facial nerve)
• Lower molar, incisor and canine teeth and the associated gingiva
• Motor Supply:
• Muscles of mastication; medial pterygoid, lateral pterygoid, masseter,
temporalis
• Anterior belly of the digastric muscle and the mylohyoid muscle (these
are suprahyoid muscles)
• Tensor veli palatini
• Tensor tympani
• Parasympathetic supply to submandibular, sublingual & parotid glands.
 OPHTHALMIC DIVISION (V1)
• It is purely sensory.
• Gives further 3 main branches:
• Frontal:
• Supra orbital & supra trochlear nerves, which leave the orbital cavity &
supply frontal air sinus & skin of forehead & scalp.
• Lacrimal:
• Joined by zygomaticotemporal branch of maxillary nerve, which contains
parasympathetic secretomotor fibers to lacrimal gland. It enters lacrimal
gland and gives branches to conjunctiva and skin of upper eyelid.
• Nasociliary:
• Continues as ant. Ethmoid nerve to enter cranial
cavity  descends to enter nasal cavity, giving off two
internal nasal branches supplies skin at tip of nose
with external nasal nerve and its branches are:
• Sensory fibers to ciliary ganglion, long & short ciliary
nerves containing sympathetic fibers to dilator
pupillae muscle & sensory fibers to cornea,
infratrochlear nerve which supplies skin of eyelids,
and Posterior ethmoidal nerve which is sensory to
ehtmoid and sphenoid sinuses.
 MAXILLARY DIVISION (V2)
• Purely sensory.
• Gives rise to 14 terminal branches, which innervate
the skin, mucous membrane and sinuses of derivatives
of the maxillary prominence of 1st pharyngeal arch.
• Passes through foramen rotundum to enter
pterygopalatine fossa.
• Continues as infra-orbital nerve and emerges on face
through infra-orbital foramen. It gives sensory fibers
to skin of face and side of the nose.
• Branches:
• Meningeal branches
• Zygomatic branch, divided into zygomaticotemporal &
zygomaticofacial supplying skin of face. Also gives
communicating branches to lacrimal nerve
• Ganglionic branches to (sensory root of) pterygopalatine
ganglion.
• Posterior superior alveolar nerve  maxillary sinus as well as
upper molar teeth& adjoining parts of gum & cheek.
• Middle superior alveolar nerve  maxillary sinus as well as
upper premolar teeth, gums & cheek.
• Anterior superior alveolar nerve  maxillary sinus as well as
upper canine & incisor teeth.
• Greater & lesser palatine nerves  palate, tonsil & nasal cavity
• Pharyngeal branch  roof of nasopharynx
 MANDIBULAR DIVISION(V3)
• Both motor & sensory.
• Sensory root leaves the trigeminal ganglion &
passes out of skull through foramen ovale to
enter into infratemporal fossa.
• Motor root also leaves skull through foramen
ovale & joins sensory root to form trunk of V3
 small ant. & large post. Division.
Branches from main trunk of V3:
• Meningeal branch
• Nerve to medial pterygoid  not only medial
pterygoid, but also tensor veli palatini (motor)

Branches from Ant. Division of V3:

•Masseteric nerve  masseter muscle
•Deep temporal nerves  temporalis muscle
•Nerve to lateral pterygoid
•Buccal Nerve  skin & mucous membrane of
cheek (only sensory)
Branches from Post. Division of V3:
• Auriculotemporal nerve  skin of auricle, external
auditory meatus, TMJ, scalp. Also postganglionic
secretomotor fibers from otic ganglion to parotid gland.
• Lingual nerve  joined by chorda tympani nerve &
supplies mucous membrane of ant. 2/3rds of tongue &
floor of mouth. Also gives preganglionic secretomotor
fibers to submandibular ganglion.
• Inferior Alveolar nerve  teeth of lower jaw through
mental foramen to supply skin of chin. Also gives off
mylohyoid nerve, supplying mylohyoid muscle & ant.
Belly of digastric.
 CLINICALS:
• Corneal Reflex is the involuntary blinking of eyelids –
stimulated by tactile, thermal or painful stimulation of
cornea. In corneal reflex, ophthalmic nerve acts as
afferent limb, detecting stimuli. If corneal reflex is absent,
it is a sign of damage to trigeminal nerve.
• Inferior alveolar nerve block: This nerve, forms the
inferior dental plexus in mandibular canal which
innervates lower teeth. In some dental procedures which
require a local anaesthesia, the nerve is blocked before
giving rise to the plexus. The anaesthetic solution is
administered at mandibular foramen, causing numbness
of area supplied by this nerve. The fluid also spreads to
lingual nerve, causing numbness in ant. 2/3 of tongue.
• Trigeminal Neuralgia: Pain along the distribution of nerve
which is caused due to local lesion of unknown cause. The
principal disease affecting sensory root of V nerve is
characterized by attacks of severe pain in area of
distribution of max. or mand. divisions. Maxillary nerve is
most frequently involved.
• Trigeminal ganglion harbours herpes zoster causing
shingles in the ditribution of nerve.
• Flaccid paralysis of muscles of mastication in injury of
mandibular nerve leading to decrease strength for biting.
• Hypoacusis, i.e. partial deafness to low pitched sounds
due to paralysis of tensor tympani.
• In injury to maxillary nerve, there is loss of sneeze reflex.
• Testing for sensory supply: ask the patient to
close their eyes & introduce a cotton wisp to areas
of face supplied by three divisions of trigeminal
nerve to detect tactile sensory competence.
• Testing motor supply: ask the patient to clench
their jaw as you palpate superior to zygomatic
arch to feel for contraction of temporalis & then
repeat palpating inferiorly to masseter. Ask
patient to open their mouth and deviate their
mandible to right & left to check competence of
medial & lateral pterygoids.