KMCT DENTAL COLLEGE

MANASSERY P.O, MUKKAM

DEPARTMENT OF ORAL AND

MAXILLOFACIAL SURGERY

SEMINAR ON : TRIGEMINAL NERVE

SUBMITTED BY:

ANU .M. PAUL

FINAL YEAR PART II

REG NO:160020963

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 CERTIFICATE

This is to certify that ____ANU .M. PAUL _____

Reg No: 160020963 has satisfactorily completed the
seminar in Department of ORAL AND
MAXILLOFACIAL SURGERY for the Fourth year
part II BDS course during the year 2021.

Date:

Lecture in charge:

Internal Examiner:

External Examiner: Head of Department:

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 INDEX

SL.NO CONTENTS PAGE NO:

1 INTRODUCTION 4

2 DISTRIBUTION OF 6
TRIGEMINAL NERVE
3 BRANCHES OF TRIGEMINAL 7
NERVE
4 OPTHALMIC DIVISION 9

5 MAXILLARY DIVISION 11

6 MANDIBULAR DIVISION 17

7 CLINICAL CORRELATION 20

8 CONCLUSION 23

9 REFERENCE 24

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 INTRODUCTION
Trigeminal nerve:

 It is the largest cranial nerve

 Transmits sensation from the skin of the anterior part of the head, the oral
and nasal cavities, the teeth and the meninges.
 It has three branches:
a) Ophthalmic nerve (V1)
b) Maxillary nerve (V2)
c) Mandibular nerve (V3)
 It is composed of
i) Small Motor Root
ii) Large Sensory Root

MOTOR ROOT

Motor root arises separately from sensory root, originating in main nucleus
with Pons and medulla oblongata. Its fibers travel anteriorly along with the sensory
root to the region of semi lunar ganglion/ gasserian ganglion.

i) At the sensory ganglion, the motor root passes in a lateral and inferior direction
under the ganglion, towards foramen ovale, through which it leaves middle
cranial fossa, along with sensory root of mandibular nerve.
ii) After leaving the skull, motor root unites with sensory root of mandibular division
to form a single trunk.

Muscle supply:

i) Masticator muscles- temporalis, masseter, medical pterygoid and lateral

pterygoid
ii) Mylohyoid
iii) Anterior belly of digastric
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 iv) Tensor tympani
v) Tensor veli palatine

Motor root within pons &

medulla

Lateral & inferior direction, under

semilunar ganglion

Foramen ovale

Unites with mandibular division

of sensory root to form single
trunk

SENSORY ROOT

It comprises of central process of ganglion cells in trigeminal ganglion.

There are 2 ganglia; innervating each side of face. They are located in Meckel’s
cave, on anterior surface of petrous temporal area.

Sensory root fibers enter the ganglia and exit as 3 sensory division:

 Ophthalmic (V1)
 Maxillary (V2)
 Mandibular (V3)

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 DISTRIBUTION OF TRIGEMINAL NERVE

Nerve/Division Distribution

Ophthalmic Upper third of the face including eyeball, conjunctiva, nasal

(sensory) cavity, lacrimal gland, scalp up to vertex. Ophthalmic nerve
also forms the afferent limb of corneal reflex

Maxillary (sensory) Middle third of the face including most of nasal cavity, upper
teeth and gums, maxillary sinus, mucous membrane of
pharynx, palate, dura mater of middle cranial fossa. Maxillary
nerve conveys secretomotor fibres to the lacrimal gland and the
glands of palate, nose, and oral cavity

Mandibular (mixed) Sensory: Lower third of the face (except the small area over the
angle of mandible) including part of auricle, temple Motor:
Muscles of mastication, mylohyoid, anterior belly of digastric,
tensor palati, and tensor tympani. Mandibular nerve forms both
the limbs of masticatory reflex

BRANCHES OF TRIGEMINAL NERVE

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 AE = anterior ethmoidal, IT = infratrochlear, PE = posterior ethmoidal,
SO = supraorbital, ST = supratrochlear, V1 = ophthalmic division,
V2 = maxillary division, V3 = mandibular division 1 = ciliary ganglion, 2 =
pterygopalatine ganglion, 3 = otic ganglion, 4 = submandibular ganglion.

OPHTHALMIC DIVISION
Frontal branch:

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 1. Supraorbital - upper eyelid, conjunctiva
2. Supratrochlear -frontal sinus and skin of forehead and scalp
Nasociliary branch:
a) Long ciliary nerve
b) Branch to ciliary ganglion
c) Posterior ethimoidal
d) Anterior ethimoidal
e) Infratrochlear
Lacrimal nerve:
MAXILLARY DIVISION
Within the cranium:
Middle meningeal nerve
In the pterygopalatine fossa:
i) Ganglionic branches:
 Nasopalatine nerve:
 Posterior superior lateral nasal nerve:
 Greater palatine nerve:
 Lesser palatine nerve
ii) Zygomatic nerves : zygomaticotemporal & zygomaticofacial
iii) Posterior superior alveolar nerve
In the infra- orbital canal:
i) Middle superior alveolar nerve
ii) Anterior superior alveolar nerve
On the face:
i) Inferior palpebral- skin of lower eyelid
ii) External nasal- skin on lateral aspect of nose
iii) Superior labial- skin and mucous membrane of whole of upper lip
MANDIBULAR DIVISION
Branches from undivided nerve:
a) Meningeal branch
b) Nerve to medial pterygoid
• Tensor veli palatine
• Tensor tympani
• Medial pterygoid
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Branches from anterior trunk:
a) Deep temporal nerve
b) Nerve to masseter
c) Nerve to lateral pterygoid
d) Buccal-skin of cheek
Branches of posterior trunk:
i) Auriculotemporal
a) Auricular
b) Superficial temporal
c) Articular to TMJ
d) Secretomotor to parotid
ii) Lingual
iii) Inferior alveolar nerve
• Incisive nerve
• Mental nerve
• Mylohoid nerve

OPHTHALMIC DIVISION
 1st and the smallest branch
 Originates from trigeminal ganglion in middle cranial fossa.
 Passes anteriorly through lateral wall of cavernous sinus.
 Enters orbit via superior orbital fissure.
 Transmits sensory fibers from the
o Eyeball
o Skin of upper face
o Anterior scalp
o Lining of upper part of nasal cavity
o Meninges of anterior cranial fossa.
 Before passing through superior orbital fissure, divides into 3 main branches
i) Frontal
ii) Nasociliary
iii) Lacrimal

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Frontal branch:

 Largest branch of V1
 Passes through superior orbital fissure and passes immediately below the
frontal bone and divides into
 Supraorbital (larges and lateral branch)
 Supratrochlear (smaller and medial branch)
 Supplies frontal sinus and skin of forehead and scalp

Nasociliary branch:

 Passes through superior orbital fissure within common tendinous ring

medial to orbital root.
 It divides into
f) Short ciliary nerve
g) Long ciliary nerve

These nerves pass to eyeball to intervate ocular structures including cornea.

Lacrimal nerve:

 Smallest branch

 Supplies lacrimal gland and a small area of adjacent skin and conjunctiva.
 Passes through superior orbital fissure.
 Joined by postganglionic parasympathetic fibers from pterygopalatine
ganglion.
 Enters orbit with zygomatic nerve for distribution to lacrimal gland.

MAXILLARY DIVISION
o Arises from middle of trigeminal ganglion.

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o Purely sensory in function
o Gives of meningal branch in middle cranial fossa
o Runs forwards through lower part of lateral wall of cavernus sinus.
o Directed through foramen rotandum, into uppermost part of pterygopalatine
fossa between pterygoid plates of sphenoid bone and the palatine bone.
o As it crosses pterygopalatine fossa, it gives off its main branches to
perygopalatine ganglion; posterior superior alveolar nerve and zygomatic
branches.
o Enter orbit through inferior orbital fissure.
o Within orbit, occupies infra-orbital groove and becomes infra-orbital nerve-
crosses anteriorly into infra-orbital canal.
o Maxillary nerve emerges on anterior surface of face through infra-orbital
foramen where it divides into its terminal branches, supplying skin of middle
portion of face, nose, lower eyelid and upper lip.

Trigeminal ganglion

Lateral wall of cavernus

sinus

Foramen rotandum

Pterygopalatine fossa

Posterior surface of
maxilla

Orbit through infra-

orbital fissure

Maxillary nerve innervates:

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 1. Skin of
i) Middle portion of face
ii) Lower eyelid
iii) Side of nose
iv) Upper lip
2. Mucous membrane of
i) Nasopharynx
ii) Maxillary sinus
iii) Soft palate
iv) Tonsil
v) Hard palate.
3. Maxillary teeth and periodontal tissues

Branches:

Maxillary nerve gives off branches in four regions.

a) Within the eranium

b) In the pterygopalatine ganglion
c) In the infraorbital canal
d) On the face

Within the cranium:

Middle meningeal nerve

 Immediately after separating from trigeminal ganglion

 Travels with middle meningeal artery
 Sensory innervations to duramater of anterior half of middle cranial fossa.

In the pterygopalatine fossa:

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 iv) Pterygopalatine nerves
v) Zygomatic nerves
vi) Posterior superior alveolar nerve

Pterygopalatine nerves:

 2 short nerves ; that suspends pterygopalatine ganglion

 Redistributed into many branches.
 Communication between pterygopalatine ganglion and maxillary nerve.
 Branches includes those supply: orbit, nose, palate, pharynx
i) Orbital branches:
Supply periosteum of orbit
ii) Nasal branches:
Supply - mucous membrane of superior and middle conchae
- lining of posterior ethmoidal sinus
- Posterior portion of nasal septum.

a) Nasopalatine nerve:

Enters sphenopalatine foramen, crosses roof of nasal cavity

Continue downward reaching floor of nasal cavity

Gives off branches to anterior part of nasal septum and floor of nose

Enters incisive canal- incisive foramen – oral cavity

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 Right and left nasopalatine nerves emerge together through incisive
foramen and supply palatal mucosa of premaxilla.

b) Posterior superior lateral nasal nerve:

Enters sphenopalative foramen

Supply posterior-superior quadrant of lateral wall of nose

iii) Palatine branches:
a) Greater palatine nerve:
Descends down through pterygopalatine canal

Emerges on hard palate through greater palatine foramen (distal to 2nd Molar)

Multiple branches supply posterior- inferior quadrant of lateral wall of nose and
adjacent floor of nose

Nerve courses anteriorly, after emerging from greater palatine foramen between
mucoperosteum and osseus hard palate

Sensory innervations to palatal soft-tissues and bone anterior to 1st premolar

Communicates with fibers of nasopalatine nerve

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 b. Lesser palatine nerve:
- Sensory to soft palate
- Descent through lesser palatine foramina in palatine bone and pass
backwards to supply inuiosis membrane on both surfaces of soft
palate
c. Pharyngeal branch:
- Leaves posterior part of pterygopalatine ganglion, through
pharyngeal canal
- Supply nasopharynx, posterior to auditory tube

Zygomatic nerves:

 Provides sensory inervation to skin over zygomatic region

 Divides into 2 branches
- Zygomaticotemporal nerve
- Zygomaticofacial nerve

Posterior- superior alveolar nerves:

 Descend from main trunk of maxillary nerve in pterygoapalative fossa

before entering infra-orbital canal.
 2 branches; one branch provide sensory innervations to buccal gingival in
maxillary molar region and adjacent facial mucosal surfaces
 Other branch provides sensory innervations to mucous membrane of sinus.
 Containing downward, this branch provides sensory innervations to alveoli,
perodental ligaments, pulpal tissues of maxillary molars.

In the infra- orbital canal:

iii) Middle superior alveolar nerve

iv) Anterior superior alveolar nerve

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Middle superior alveolar nerve:

 Branches within infra- orbital canal

 Supplies 2 maxillary premolars and mesiobuccal root of maxillary 1 st molar,
periodontal tissues, buccal soft tissue and bone in premolar region.

Anterior superior alveolar nerve:

 Just before exit from infraorbital foramen

 Descend within anterior wall of maxillary sinus
 Supplies:
- Pulpal innervations to central incisors, lateral incisors and canine.
- Periodontal ligament, buccal bone and buccal gingival

These nerves makes network, termed as dental plexus.

Superior dental plexus:

- Composed of small nerve fibers from 3 superior alveolar nerves-

anterior, middle and posterior superior alveolar nerves.
- 3 types of nerves emerges from these plexus
i) Dental nerves
ii) Interdental branches
iii) Inter radicular branches

On the face:

iv) Inferior palpebral- skin of lower eyelid

v) External nasal- skin on lateral aspect of nose
vi) Superior labial- skin and mucous membrane of whole of upper lip

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MANDIBULAR DIVISION
 Nerve of 1st brachial arch
 Largest branch
 Mixed nerve with 2 roots
 Emerges separately through foramen ovale
 Unites outside skull and form main trunk
 Main trunk undivided for 2-4 mm and then into small anterior and large
posterior trunk

Branches from undivided nerve:

a) Meningeal branch:
 re-enter cranium through foramen spinosum
 supplies- cartilaginous part of Eustachian tube
- duramater in posterior half & mastoid air cells/ antrum.
b) Nerve to medial pterygoid:
 It sinks in to deep surface of muscles.
 Supllies tensor veli palatine and tensor tympani.

Branches from anterior trunk:

 Trunk runs forwards under lateral pterygoid muscle then reaches external
surface of the muscle and continues as buccal nerve.
 Motor innervations:
e) Deep temporal nerve
f) Nerve to masseter
g) Nerve to lateral pterygoid
 Sensory innervations: buccal nerve
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  Pass between 2 heads of lateral pterygoid
 Pass down deep to temporalis
 Emerges under anterior border of masseter muscle
 At the level of ocular plane of mandibular third or second molar. Crosses in
front of anterior border of ramus and enters cheek through buccinators.
 Sensory supply to skin of cheek
Buccal gingira of mandibular molar
Muccobuccal fold

Branches of posterior trunk:

 Primarily sensory with a small motor root

 Descends inferomedially to lateral pterygoid
 Divides into
iv) Auriculotemporal
v) Lingual
vi) Inferior alveolar nerve

Auriculotemporal nerve:

Branches

i) communicating with facial nerve

ii) communicating with otic ganglion
iii) parotid gland
iv) anterior auricular branch – skin over helix and tragus of ear
v) external auditory meatus
vi) skin over tympanic membrane
vii) auricular branches to posterior portion of TMI
viii) superficial temperol branch- skin over temporal region

Lingual nerve:

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  passes downward medial to lateral pterygord
 as it descends lies in pterygomandibular space
 runs anterior and medial to inferior alveolar nerve
 continues downwards deep to pterygomandibular raphae
 to reach sides of tongue, below and behind mandibular third molars
 looping Whartoris duct, passing lateral, then medial to duct, across muscles
of tongue
 it is sensory to anterior two- third of the tongue- for general sensation and
gestation
 Also provide sensory innervations to mucous membrane of floor of mouth
and gingira on lingual side of mandible.

Inferior alveolar nerve:

Largest branch of mandibular divisions

Descends medial/deep to lower part of lateral pterygoid

Lateroposterior to lingual nerve

Between sphenomandibular ligament and medial surface of ramus of mandible

Unless mandibular and at the level of mandibular foramen

Forwards to mental foramen

Terminal branches of inferior alveolar nerve

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 i) Incisive nerve
ii) Mental nerve

Mental nerve divides into 3 branches that innervates

a) Skin of chin
b) Skin and
c) Mucous membrane of lower lip

Mylohoid nerve:

 Prior or entry of inferior alveolar nerve to mandibular canal

 Runs downwards and forwards in mylohyoid groove on medial surface of
ramus to reach mylohyoid muscle
 Motor to mylohyoid muscle and anterior belly of digastrics
 Sensory innervations
Rarely to skin on inferior and anterior surface of mental protuberance,
Rarely to mandibular incisors and molars (usually mesial root of mandibular
1st molar)

CLINICAL CORRELATION
Trigeminal neuralgia (tic douloureux): It is a clinical condition which presents as a
paroxysmal episodes of severe pain of sudden onset and short duration in the area
of distribution of one or more of the three divisions of the trigeminal nerve. The
ophthalmic division (CN V1) is not commonly involved. The most commonly
trigeminal neuralgia is associated with maxillary (CN V2) and mandibular
divisions (CN V3) of the trigeminal nerve. It is often associated with dental caries.

Clinical Characteristics

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TN typically 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, across the distribution of one or
more branches of the trigeminal nerve.
• Pain rarely crosses the midline
• The pain is of short duration and lasts for a few seconds, but may recur with
variable frequency. Even though there is a refractory period (complete lack of
pain) between the attacks, some patients report a dull ache in between the attacks
• During an attack, the patient grimaces with pain, clutches his hands over the
affected side of the face, stopping all the activities and holds or rubs his face,
which may redden or the eyes water until the attack subsides.

Medicinal Management
Carbamazepine (Tegretol) and phenytoin (Dilantin) are the traditional
anticonvulsants used

 Baclofen
 Gabapentin
 Lamotrigine
Surgical Treatments
 Peripheral Anesthetic / Alcohol Injections
 Peripheral Neurectomy
 Direct applications of cryotherapy probe at temperatures colder than –
60ºC are known to produce Wallerian degeneration without
destroying the nerve sheath itself.

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CONCLUSION
Trigeminal nerve is located within the brain and is responsible for
transmitting sensations from face to brain. It is responsible for transmitting
sensations to mouth, teeth, face and nasal cavity. It is also the nerve that controls
the muscles used for chewing. Trigeminal neuralgia occurs, when a blood vessel,
either a vein or artery, puts pressure on the nerve at base of brain.. It has been an
enigma to physicians for a long course of time. There have been various advances
in the understanding of the pathogenesis of the disease and the treatment
modalities. However various treatment modalities suggests dissatisfaction with any
one single procedure. Hence the golden rule still remains optimum scrutinization
and authentic diagnosis which is a key to the success of any treatment.

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REFFERNCE

 Text book of Human Anatomy- volume 3 Head & Neck- B.D Chaurasia

 Text book of Human Anatomy- volume 3 Head & Neck- Vishram Singh.

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