TRIGEMINAL NERVE

-DR. TANU SHREYA

1ST PGT (DEPARTMENT OF PROSTHODONTICS)
HCDSH
2 CONTENTS

• INTRODUCTION
• ORIGIN
• COURSE
• DISTRIBUTION
• CLINICAL EXAMINATION
• CLINICAL ANATOMY
• PROSTHODONTIC IMPLICATIONS
• REFERENCES
3 INTRODUCTION

Nerves of human body depending upon their exit fron cranium are divided into
Cranial nerves and Spinal nerves.
There are 12 pairs of Cranial nerves.
And 31 pairs of Spinal nerves in human body.
TRIGEMINAL NERVE IS THE 5TH CRANIAL NERVE.
IT IS A MIXED NERVE AND THE LARGEST OF ALL CRANIAL NERVES.
4 CRANIAL NERVES

Mnemonic for cranial nerves –

Oh,
Oh,
Oh,
Try,
Try,
Again,
Failure,
Victory,
Give,
Value,
And,
Happiness.
5 ATTACHMENTS OF CRANIAL NERVES

• I, II – from fore brain

• III, IV – from midbrain
• V, VI,VII, VIII – from pons
• IX, X, XI, XII – from medulla oblongata.
6 FORMATION

• Trigeminal nerve is largest cranial nerve composed of small motor root and
considerably large sensory root.
NUCLEAR COLUMNS

GENERAL SOMATIC BRANCHIAL EFFERENT

AFFERENT COLUMN COLUMN
THIS HAS 3 NUCLEI: IT HAS 1 NUCLEUS
• SUPERIOR SENSORY • MOTOR NUCLEUS OF
NUCLEUS CN-V
• SPINAL NUCLEUS
• MESENCEPHALIC
NUCLEUS
7 NUCLEI OF TRIGEMINAL NERVE

1. MAIN/ SUPERIOR SENSORY NUCLEUS: Lies in posterior part of pons

lateral to motor nucleus. It is continuous below with spinal nucleus.

Function:-GSA- Touch, pressure from skin and mucous

membrane of facial region.
8 2. SPINAL NUCLEUS: It extends inferiorly through upper pons to second
cervical segment of spinal cord.

Function:- GSA- Pain and temperature from skin of face.

3. MESENCEPHALIC NUCLEUS:- It is composed of unipolar cells situated

in lateral part of gray matter around the cerebral aqueduct. It extends
inferiorly ifrom midbrain nto pons .

Function:- It serves as afferent station that receives proprioception

impulses from temporomandibular joint, periodontal ligaments,
muscles of mastication and facial and extra ocular muscles.
 4. MOTOR NUCLEUS:- It is situated in pons medial to sensory nucleus. The
fibres of motor nucleus supply the eight muscles derived from 1st branchial
9 arch.

Function:- BE- Movement of mandible.

10 TRIGEMINAL GANGLION(GASSERIAN
GANGLION)
Crescent , semilunar shaped
- Placed in a depression on anterior aspect at the apex of
petrous temporal bone known as trigeminal impression
-It is enclosed within a pouch like recess of dura
matter known as trigeminal cave.
Contains cell bodies of sensory nerve fibres of trigeminal nerve.
11

Diagram showing relations of trigeminal ganglion

and the nucleus.
12 SENSORY COMPONENT OF TRIGEMINAL NERVE

• General somatic afferent columns- carry sensations towards the CNS.

• AREAS SUPPLIED- sensation of pain, temperature , touch and pressure from
1. skin of face
2. mucous membrane of nose
3. most of tongue
4. paranasal sinuses
Follows an onion skin pattern in its distribution.
13 PATHWAY OF SENSORY INPUT

• Impulses of sensation travel via axons , the cell bodies of which relay in
the Trigeminal ganglion.
• The central process of ganglion forms sensory root, it branches into
-ascending fibres- ends in Superior sensory
nucleus(pressure)
- descending fibres- ends in spinal nucleus(pain, temperature)
• Proprioceptive fibres bypass the ganglion to reach unipolar cells of
mesencephalic nucleus in midbrain.
14
15 MOTOR COMPONENT OF TRIGEMINAL NERVE

• The motor nucleus(branchial efferent) receives impulses from-

1. right and left cerebral hemispheres
2. red nucleus
3. mesencephalic nucleus.
8muscles supplied by motor root- 4 muscles of mastication
And 4 other muscles developing from 1st branchial arch- tensor tympani,
tensor veli palatini, mylohyoid and anterior belly of digastric.
16
17 DIVISION OF TRIGEMINAL NERVE

OPHTHALMIC V1

Comprises of 3 branches MAXILLARY V2

MANDIBULAR V3
18 1. OPHTHALMIC NERVE

• Purely sensory

• Arise from antero-medial part of trigeminal ganglion

• After passing superior orbital fissure-enters into orbit-gives three branches

-lacrimal
-frontal
-nasociliary
19 COURSE AND DIVISIONS

• 1 FRONTAL NERVE- DIVIDES INTO

A. SUPRA TROCHLEAR- upper eyelid, conjunctiva,
lower part of forehead
B. SUPRAORBITAL- frontal air sinus,
upper eyelid, forehead, scalp till vertex.
20 2. NASOCILIARY NERVE- DIVIDES INTO
A. LONG CILIARY- SENSORY TO EYEBALL
B. POSTERIOR ETHMOIDAL- to sphenoidal and posterior ethmoidal air
sinuses
C. BRANCH TO CILIARY GANGLION
D. INFRATROCHLEAR
E. ANTERIOR ETHMOIDAL- to middle and anterior ethmoidal air sinuses
 21 AUTONOMIC GANGLION ASSOCIATED WITH
OPHTHALMIC DIVISION
Ciliary ganglion:- It is located near apex of orbit between optic nerve & origin of lateral
rectus muscle.
Roots:-
1.Sensory roots:- It comes from nasociliary nerve. It carries sensory fibers from eye ball.

2.Motor root:- arises from oculomotor nerve(CN 3). It carries preganglionic fibers from
Edinger- Westphal nucleus. Post ganglionic fibers pass through short ciliary nerve and
supply to cilliaris and sphincter pupillae muscles.
22 Sympathetic root:- derived from branch of internal carotid
plexus carries post ganglionic fibers of superior cervical
ganglion to supply blood vessels of eyeball and dilator pupillae
23 3. LACRIMAL NERVE- TO LATERAL PART OF UPPER EYELIDS.
CONVEYS SECRETOMOTOR FIBRES FROM ZYGOMATIC NERVE TO
LACRIMAL GLANDS.
24 2. MAXILLARY NERVE

• Purely sensory
• Arises from middle of the distal edge of trigeminal ganglion
• Lie in lower part of lateral wall of the cavernous sinus
• LEAVES CRANIUM TO ENTER FACE THROUGH FORAMEN
ROTUNDUM.
25
26 COURSE AND DISTRIBUTION

• IN MIDDLE CRANIAL FOSSA- MENINGEAL BRANCH

 IN PTERYGOPALATINE FOSSA-
27
• GANGLIONIC BRANCHES TO PTERYGOPALATINE GANGLION
• 2 ZYGOMATIC BRANCHES- ZYGOMATICOTEMPORAL
-ZYGOMATICOFACIAL
• POSTERIOR SUPERIOR ALVEOLAR
 28
IN INFRAORBITAL CANAL-
MIDDLE SUPERIOR ALVEOLAR
ANTERIOR SUPERIOR ALVEOLAR

ON FACE (through infraorbital

foramen)-
INFRAORBITAL NERVE
PALPEBRAL
LABIAL
NASAL
29 3. MANDIBULAR NERVE

• Largest branch of CN-V Arises from lateral part of trigeminal ganglion.

• Mixed nerve- has both motor and sensory components.
30 COURSE AND DIVISION

• Nerve formed by union of 2 roots-

SENSORY MOTOR

Motor root unites with sensory

Just below the foramen
Both roots leaves skull
through foramen ovale

After emerging the foramen

Nerve enters infratemporal fossa
31
32 BRANCHES

• MAIN TRUNK- a.Meningeal branch also called nervous spinosus

b.Nerve to medial pterygoid- (supplies motor)- tensor veli palatini
-tensor tympani
-medial pterygoid muscle
• ANTERIOR DIVISION to- deep temporal
-lateral pterygoid
-masseteric
-buccal- sensory to skin of cheek.
 POSTERIOR DIVISION- Gives off 3 main branches:
1. AURICULOTEMPORAL NERVE- gives of
33 a. auricular
b.superficial temporal
c.articular to TMJ
d. secretomotor to parotid gland.

2. LINGUAL NERVE – general sensation to anterior 2/3rd of tongue

3. INFERIOR ALVEOLAR NERVE –enters mandibular canal to supply

lower teeth, branches into
- mental nerve for skin of chin and nerve to mylohyoid(motor) to
-mylohyoid and anterior belly of digastric
34
35 CLINICAL EXAMINATION

SENSORY
-Test light touch and superficial pain in the territories of
V1,V2,V3.

- using a pinprick to test facial sensation and by brushing a wisp of cotton

against the lower or lateral cornea to evaluate the corneal reflex

-Use orange stick to check touch sensation on ant two-third of

the tongue.
36
37

MOTOR-
Check wasting of muscles

-to check the masseters, estimating

their bulk, the patient is asked to
clench the teeth
-Ask the patient to open the jaw
against resistance-look for any
deviation to check pterygoids
- Chin deviates to the weak pterygoid side.
38 CORNEAL AND JAW JERK REFLEX

CORNEAL REFLEX
-Ask the patient to look upward to the ceiling and gently depress the lower eyelid
-Lightly touch the lateral edge of the cornea with damp cotton wool
-Look for both direct and consensual blinking
- It is lost in CN-5 damage.
39 JAW JERK REFLEX

-Ask the patient to let his mouth hang losely

-Place finger in the midline between lower lip
and chin.
-Percuss with finger and tendon hammer.
40 CLINICAL ANATOMY

1) Due to involvement of sensory distribution of trigeminal nerve-HEADACHE-common symptom in

involvement
-of nose (common cold)
-sinusitis
-infections of teeth & gums
-glaucoma

2) Due to paralysis of masseter & temporalis muscle laxity & atrophy difficulty in closing, opening &
clenching the mouth
41

3) Paralysis of the pterygoid muscle chin of one side is pushed to the paralysed side
by muscle of opposite side.
4) Loss of sensation in ophthalmic division.
• (nasocilliary nerve)

• loss of blinking
(corneal reflex)
Formation of ulcers
on the cornea BLINDNESS
42

Pain in different teeth referred to

different parts of the face
43 6) Mandibular nerve block used to anaesthetize the lower jaw (for
extraction of teeth)

7) Lingual nerve lies close to medial side of 3rd molar can be

injured in careless extraction

8) In cases of cancer of the tongue have intractable pain lingual

nerve can be cut to relieve pain
44 9. TRIGEMINAL NEURALGIA(TIC DOULOUREUX , FOTHERGILL’S
DISEASE.

- orofacial neuralgia which mainly follows 2nd & 3rd division of 5th cranial n.
& almost always exhibit trigger zone
- It is named tic douloreux because of spasmodic contraction of facial
muscles.
C/F-
-seldom occur before 35 years age, unilateral.
- ♀ >♂
- right side > left
45 Trigger zone
vermilion border of lips, alae of nose, cheeks &
around eyes

Pain– searing , stabbing/ lancinating type

precipitated by light touch on trigger zone

Early stages- pain mild dull aching or burning

resembling sharp toothache.

Each attack persists for few seconds - several

minutes.
46 Rx-
1. Earliest- peripheral neurectomy at
mental / supraorbital/ infraorbital
foramen, but it gives only temporary
relief

2. Injection of alcohol / phenol /

boiling H2O into peripheral n /
centrally into gasserion ganglion, but
temporary relief only ( 6mths-
several yrs )
47
48 3. Drugs- phenytoin for
management & carbamazepine
for diagnostic purpose.

4. Microsurgical decompression of
trigeminal root by inflatable
balloon – newest procedure
49 10. HERPES ZOSTER(SHINGLES , ZONA)

-Acute infectious viral disease characterized by inflammation of dorsal root / or extramedullary cranial n.
ganglia.

C/F- characterized by a unilateral painful skin rash in one or more dermatome distributions
of the fifth cranial nerve (trigeminal nerve), shared by the eye and ocular adnexa

-nerves 5th nerve (mostly ophthalmic) C3,T5,L1,L2

50

• Diagnosis—
a. Viral isolation– tissue culture
b. Fluorescent antibody staining technique

• Rx –
Antiviral drugs- acyclovir ,valcyclovir
corticosteroids to reduce inflammation.
51 PROSTHODONTIC IMPLICATIONS

• Prosthodontics difficulty in patients with trigeminal neuralgia –

• Trigger zones are triggered during impression making, jaw relation and establishing
occlusion during fabrication of dentures.
• Trigger zones are also stimulated in old patients having overclosure denture and in long
time denture wearers without compensating ridge resorption.

Maria Cristina ;Sliding Plates on Complete Dentures Jul 2016. The

Journal of Craniomandibular & Sleep Practice
52 MODIFICATION IN NEURALGIA PATIENTS

• Temporary complete dentures with sliding plates are fabricated to reestablish the vertical
dimension at occlusion and also provide deprogramming of neuromuscular process and
jaw closures in physiologic postures.

Maria Cristina ;Sliding Plates on Complete Dentures Jul 2016. The

Journal of Craniomandibular & Sleep Practice
53

• . By increasing jaw separation with an acrylic biteplane in lower denture provides flat
surfaces against upper denture so that muscles are in normal physiological position. After
pain is relieved, new dentures with same jaw relation can be fabricated
54

• c. Laser therapy increases blood flow, oxygenation and has analgesic effects. It is
followed by interocclusal splint to reestablish occlusion and then removable dentures are
fabricated with properly mechanical and functional support
 TRIGEMINAL NERVE BRANCH INJURIES ASSOCIATED WITH
55 DIFFERENT PROSTHODONTIC PROCEDURES- REMOVABLE
PROSTHESIS

• 1. After extraction, there is accentuated bone resorption in both arches

leading to nerve exposure on the surface of alveolar ridges, which is more
susceptible for trauma while using removable dentures.
• 2. The neurological disturbance resulting from pressure on the mental
foramen/mental nerve generated by a complete denture leading to lower
lip paresthesia.
• 3. Pressure on incisive foramen due to maxillary anterior ridge resorption
leads to paresthesis of upper lip as nasoplatine nerve passes through it.
56 MANAGEMENT

• Adequate relief in the areas such as mental foramen, incisive papilla

should be provided.
• If nerve injuries occur, then commercially available topical application of
anaesthetics are used to relieve pain eg-lidocaine and benzocaine and
vanilloid compounds (capsaicin)

Dr. Manu Rathee; Prosthodontic implications of Nerves of orofacial region-A review Volume 8 Issue 3
November 2021Asia pascific Journal
57 IMPLANTOLOGY

• During implant placement, there is chance for damage to the inferior alveolar nerve, mental nerve and
incisive nerve in mandibular region, nasopalatine canals, and posterior alveolar nerve in maxillary region.
MANAGEMENT
• It is recommended that a clearance of at least 3mm of bone from the top of the mandibular canal,
5mm from mental foramen and
1mm from nasal cavity and maxillary sinus.
• To prevent nerve injury during implant placement, drill guards are used.
58
59 CONCLUSION

• Trigeminal nerve is the main nerve that provide sensory and few motor innervation to
most parts of face. Therefore profound knowledge of the anatomy, physiology and
distribution of trigeminal nerve is essential to know its location for the fabrication of
dentures since many surgical and non-surgical procedures performed by a prosthodontist
may have the possibility of causing injury to peripheral branches of this cranial nerve.
60 REFERENCES

• BD Chaurasia’s Human Anatomy – 6th edition

• Textbook of Anatomy – I.B Singh -4th edition
• Grays Anatomy
• Atlas of Anatomy- Joseph J. Warner
• Clinical Neuroanatomy- Richard.S.Snell
• Clinical medicine – Kumar & Clarke
• Oral Medicine – Burket’s – 10th edition
• Text of oral pathology – Shafer’s – 5th edition
• Grants atlas of Anatomy– 10th edition

• Dr. Manu Rathee; Prosthodontic implications of Nerves of orofacial region-A review Volume 8 Issue 3
November 2021Asia pascific Journal

• Maria Cristina ;Sliding Plates on Complete Dentures Jul 2016. The Journal of Craniomandibular & Sleep
Practice
61

•THANK YOU.