This document provides information on the nerve and blood supply to permanent teeth. It discusses the branches of the trigeminal nerve (CN V) that provide innervation, including the ophthalmic, maxillary, and mandibular nerves. It describes the individual branches that innervate each region of the teeth. It also discusses the blood supply from branches of the external carotid artery and the arteries that provide blood to the maxilla and mandible. Clinical considerations related to damage or irritation of the nerves are presented.

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2. BLOOD SUPPLYAND NERVE
SUPPLYTO THE PERMANENT
TEETH
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3. CONTENTS
◦ Introduction
◦ Innervation of the teeth- Trigeminal nerve:
◦ Ophthalmic nerve
◦ Maxillary nerve and its branches
◦ Mandibular nerve and its branches
◦ Clinical considerations
◦ Blood supply to permanent teeth
◦ Arterial and venous supply
◦ Clinical considerations
◦ References.
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4. INTRODUCTION
◦ The nervous system is an organ system containing a network of
specialized cells called neurons that transmit signals between
different parts of the body & coordinate the actions.
◦ This system can emit and receive thousands of bits of
information, integrate them, and determine the response to be
made by the body
◦ The nervous system consists of two parts,
◦ 1. Central nervous system
◦ 2. Peripheral nervous system.
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5. ◦ Blood supply to the teeth is provided by various arteries
and veins.
◦ These provide the required nutrients, oxygen, blood cells
and in turn carry away the carbon dioxide and the other by
products.
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6. INNERVATION OF THE TEETH
◦ The maxillary and mandibular teeth are innervated by the
branches of fifth cranial nerve - Trigeminal nerve
◦ The nerve arises from semilunar ganglion(a.k.a gasserian
ganglion) which is present on the middle cranial fossa.
◦ Occupies a cavity in the dura mater covering the trigeminal
impression near the apex of the petrous part of the temporal bone.
◦ It is in relation with the internal carotid artery and the posterior
part of the cavernous sinus
◦ It give off minute branches to the tentorium cerebelli, and to the
dura mater in the middle fossa of the cranium.
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7. Trigeminal Nerve: (CN V) has 2 roots:-
◦ The larger sensory root and
◦ The smaller motor root.
 Two sensory branches & one Mixed
◦ Ophthalmic branch (S)supplies the orbit and forehead
◦ Maxillary branch (S) supplies the maxillary sinus and upper
jaw teeth
◦ Mandibular branch (M)supplies the tongue and the lower
jaw teeth
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8. MOTOR ROOT
◦ The motor root arises separately from the sensory root
originating in the motor nucleus within the pons and
medulla oblongata.
◦ Its fibers forming a small nerve root travel anteriorly along
with but entirely separate from the larger sensory root to
the region of the semilunar ganglion.
◦ At the semilunar ganglion the motor root passes in a lateral
and inferior direction under the ganglion towards the
foramen ovale through which it leaves the middle cranial
fossa along with the third division of the sensory root.
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9. SENSORY ROOT
◦ Sensory root fibers of the trigeminal nerve comprise the
central processes of ganglion cells located in the trigeminal
ganglion.
◦ On entering the pons, divide into upper and lower roots
◦ The upper root ends in nucleus situated in the pons lateral
to the lower motor nucleus.
◦ The lower root descends through the pons and medulla
oblongata.
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10. TRIGEMINAL NERVE IS ASSOCIATED WITH THREE
DIVISIONS AND FOUR GANGLIA
◦ Ciliary ganglion associated with ophthalmic nerve
◦ Sphenopalatine ganglion associated with maxillary nerve
◦ Otic ganglion and
◦ Sub maxillary ganglion associated with mandibular nerve
◦ All four ganglia receive:-
◦ Sensory filaments from the trigeminal nerve
◦ Motor and sympathetic filaments from various source.
◦ These filaments are called as ROOTS OF GANGLION.
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12. INNERVATION BY THE BRANCHES
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13. OPTHALMIC NERVE
◦ The ophthalmic nerve (CN V1) is the first branch of the
trigeminal nerve.
◦ The ophthalmic nerve is a sensory nerve mostly carrying general
somatic afferent fibers that transmit sensory information to the
CNS from structures of the eyeball, the skin of the upper face and
anterior scalp, the lining of the upper part of the nasal cavity and
air cells, and the meninges of the anterior cranial fossa.
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14. MAXILLARY NERVE
◦ It is a sensory nerve.
◦ It is intermediate, both in position and size.
◦ It begins at the middle of the semilunar ganglion as a flattened
plexiform band, and, passing horizontally forward. It leaves the
skull through foramen rotundum. It becomes more cylindrical in
form, and firmer in texture.
◦ Then crosses the pterygopalatine fossa, enters the orbit through
the inferior orbital fissure, appears upon the face at the
infraorbital foramen.
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17. ◦ All upper teeth are innervated by the superior alveolar
plexus formed by the posterior, middle, and anterior
alveolar nerves, which originate directly or indirectly from
the maxillary nerve [V2].
◦ From the plexus, dental branches are given off to each tooth
root and interdental branches to the bone, periodontal
membrane and gingiva, the distribution being similar to that
described for the arteries.
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19. POSTERIOR SUPERIOR ALVEOLAR
NERVE
◦ It originates directly from the maxillary nerve [V2] in the
pterygopalatine fossa.
◦ It enters the maxilla through the alveolar foramen, and
passes through the bone in the wall of the maxillary sinus.
◦ It innervates the molar teeth.
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21. MIDDLE SUPERIOR ALVEOLAR
NERVES
◦ The originate from the infraorbital branch of the maxillary
nerve [V2] in the floor of the orbit.
◦ They arises from the infra- orbital nerve in the infra-orbital
groove, passes through the bone in the lateral wall of the
maxillary sinus, and innervates the premolar teeth.
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22. ANTERIOR SUPERIOR ALVEOLAR
NERVE
◦ The originates from the infraorbital nerve in the infra-
orbital canal.
◦ It passes through the maxilla in the anterior wall of the
maxillary sinus, and via the superior alveolar plexus,
supplies the canine and incisor teeth.
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23. ◦ The branches from the pterygopalatine ganglion, which run
a descending course and are distributed as follows:
◦ the greater and lesser palatine nerves, which pass through
the corresponding palatine foramina to supply the mucous
membrane of the hard and soft palates, the uvula and the
tonsils.
◦ The nasopalatine nerve supplies the nasal septum then
emerges through the incisive canal of the hard palate to
supply the incisive papilla and the gum behind the incisor
teeth. Incisive nerve.
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24. MANDIBULAR NERVE
◦ The mandibular nerve is the third division (branch) of the
trigeminal nerve.
◦ It passes through the foramen ovale and into the
infratemporal fossa.
◦ The mandibular nerve is largely sensory but it also receives
the motor fibers (axons) from the motor root of CN V that
mainly supply the muscles of mastication.
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28. ◦ The mandibular nerve almost immediately after passing
through the foramen ovale it breaks up into its several
branches.
◦ The mandibular nerve just before entering the mandibular
foramen, it releases the mylohyoid branch, which is a motor
branch to the mylohyoid muscle and anterior belly of the
digastric muscle.
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29. INFERIOR ALVEOLAR NERVE
◦ The chief branch to the lower jaw is the inferior alveolar nerve.
◦ After entering the mandibular foramen on the medial surface of
the ramus of mandible, it travels anteriorly through the bone in
the mandibular canal.
◦ During this part of its course, it gives off branches.
◦ Those dental and the interdental branches, that form the inferior
dental plexus, supply molar and premolar teeth, alveolar bone,
periodontal membrane and gingiva.
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30. ◦ Adjacent to the first premolar tooth, the inferior alveolar
nerve divides into 2 branches:
◦ the incisive branch, which innervates the first premolar, the
canine, and the incisor teeth, together with the associated
vestibular (buccal) gingiva;
◦ the mental nerve exits the mandible through the mental
foramen and innervates the chin and lower lip.
◦ Other branches of the mandibular nerve are:
◦ the buccal nerve, and
◦ the lingual nerve.
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32. INNERVATION OF SUPPORTING
TISSUES
◦ Gingiva associated with the upper teeth is innervated by branches
derived from the maxillary nerve [V2];
◦ Gingiva associated with the lower teeth is innervated by branches
of the mandibular nerve [V3].
◦ The gingiva associated with the (buccal) side of the mandibular
incisor, canine, and premolar teeth is innervated by the mental
branch of the inferior alveolar nerve.
◦ Gingiva on the buccal side of the mandibular molar teeth is
innervated by the buccal nerve, which originates from the
mandibular nerve [V3].
◦ Gingiva adjacent to the lingual surface of all lower teeth is
innervated by the lingual nerve.
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33. CLINICAL CONSIDERATION
◦ Knowledge of anatomy of the branches of the trigeminal
nerve is of utmost importance in administering local
anesthesia for oral surgical procedures
◦ Damage to the complete nerve leads to the following
features on affected side –
◦ Unilateral anesthesia on the auricle
◦ Unilateral anesthesia of the mucous membrane of mouth
◦ Unilateral anesthesia of the mucous membrane of nose
◦ Unilateral anesthesia of the anterior 2/3 of the tongue
◦ Unilateral paralysis of muscles of mastication
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34. ◦ Trigeminal neuralgia affects one or more of the divisions of
the trigeminal nerve causing severe pain.
◦ Carcinoma of the tongue which affects the lingual nerve
may refer pain to the distribution of the auriculotemporal
nerve, causing ear ache.
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35. TRIGEMINAL NEURALGIA
◦ It is also called as tic douloureux is sometimes described as the
most excruciating pain known to humanity.
◦ This intense, stabbing, electric shock-like pain is caused by
irritation of the trigeminal nerve.
◦ Anticonvulsive medications are normally the first treatment
choice.
◦ PREVALANCE:
◦ Advanced age is a major risk factor
◦ Rarely affects anyone younger than 30 years
◦ More common in women than men
◦ Hypertension and multiple sclerosis are also a risk factor
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36. ◦ Initially short, mild attacks, but trigeminal neuralgia can
progress, causing longer, more frequent bouts of searing
pain …
◦ They may also be provoked by even mild stimulation of
face.
TRIGGERS MAY INCLUDE:
◦ Shaving Stroking your face
◦ Eating
◦ Drinking
◦ Brushing the teeth
◦ Talking
◦ Encountering a breeze Smiling
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37. ◦ Post operative complications after administration of local
anaesthesia: Prolonged anaesthesia, paraesthesia
◦ Causes:
◦ Trauma to the nerve
◦ Injection of local anaesthesia solution with alcohol or cold
sterilizing solution near a nerve produces irritation and
oedema of the tissue and subsequent pressure on the nerve.
◦ Haemorrhage around the nerve sheath also causes pressure
on the nerve, leading to paraesthesia.
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38. ◦ Most paresthesias resolve within approximately 8 weeks to
2 months without treatment.
◦ Determine the degree and extent of paresthesia.
◦ Explain to the patient that paresthesia.
◦ Record all findings
◦ Second opinion
◦ Examination every 2 months
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39. BLOOD SUPPLY TO THE
PERMANENT TEETH
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40. BLOOD SUPPLY TO THE PERMANENT
TEETH
◦ The principal arteries which supply the head and neck are the
carotid arteries.
◦ The right carotid artery arises from brachiocephalic trunk in the
neck and left carotid artery arises from arch of aorta in the thorax.
◦ Common carotid artery bifurcates into external and internal carotid
arteries at the level of upper border of the thyroid cartilage.
◦ Two structures of importance at the bifurcation are Carotid sinus
and Carotid body.
◦ Carotid sinus is slight dilatation at the termination of the common
carotid artery or the beginning of the internal carotid artery. It
receives a rich innervation from the glossopharyngeal and
sympathetic nerves.
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41. ◦ FUNCTION: Carotid sinus acts as a baroreceptor or pressure
receptor and regulates blood pressure.
◦ Carotid body is a small, oval reddish-brown structure situated
behind the bifurcation. It receives nerve supply mainly from the
glossopharyngeal nerve, but also from the vagus and sympathetic
nerves.
◦ FUNCTION: Carotid body acts as a chemoreceptor and responds
to changes in the oxygen and carbon dioxide and pH content of
the blood.
◦ Internal carotid artery supplies the tissues of the cranium and the
eyes.
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43. External carotid artery
◦ ECA begins in the carotid triangle at the level of upper border of
thyroid cartilage opposite the disc between the third and fourth
cervical vertebrae.
◦ External carotid artery, with its many branches, supplies the
exterior of the head, the face and much of the neck.
◦ External carotid artery, just above its division from the common
carotid artery gives off the lingual artery which supplies the
tongue.
◦ Just above the origin of lingual artery, it gives off another
branch, the facial artery, which supplies the soft tissues of the
side of the face.
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44. Total of 8 branches
◦ ANTERIOR-Superior thyroid, Lingual, Facial
◦ POSTERIOR- Occipital, Posterior auricular
◦ MEDIAL -Ascending pharyngeal
◦ TERMINAL-Maxillary, Superficial temporal
◦ Mn: Sister Lucy's Powdered Face Often Attracts Silly
Medicos"
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46. ◦ SUPERIOR THYROID ARTERY:
◦ It arises from the external carotid artery just below the level of
the greater cornua of the hyoid bone supplies the thyroid
gland.
◦ ASCENDING PHARYNGEAL ARTERY:
◦ It is a small branch arising from medial side of the external
carotid artery supplies the pharynx.
◦ OCCIPITAL ARTERY:
◦ Arises from the posterior aspect of the ECA just above the
level of the greater cornua of the hyoid bone.
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47. ◦ It supplies the back of the scalp, sternocleidomastoid muscle
and deep muscles of the back and the neck.
◦ POSTERIOR AURICULAR ARTERY:
◦ Arises from the posterior aspect of the external carotid just
above the posterior belly of the omohyoid.
◦ It supplies the auricle, the skin over the mastoid process,
and over the back scalp. Its mastoid antrum and air cells, the
semi-circular canals, and the facial nerve.
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48. ◦ FACIAL ARTERY:
◦ It arises from the ECA just above the tip of the greater cornua
of the hyoid bone.
◦ This has a torturous course as it runs upward from cervical
part then on to the face as it enter in anteroinferior angle to
the masseter muscles, runs upwards close to the angle of the
mouth, side of the nose till medial angle of the eye.
◦ The cervical part gives off the ascending palatine , tonsillar,
submental and glandular branches for the submandibular
salivary gland and lymph nodes.
◦ The ascending palatine artery supplies the tonsils and the
root of the tongue.
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49. ◦ SUPERFICIAL TEMPORAL ARTERY:
◦ It is the smaller terminal branch of the ECA , which begins
behind the neck of the mandible under the cover of the
parotid gland.
◦ It divides into anterior and posterior branch, which supplies
the temple and scalp.
◦ The anterior branch anastomoses with supraorbital and
supratrochlear branches of the ophthalmic artery.
◦ It also gives of transverse facial artery and a middle temporal
artery, which runs on the temporal fossa deep to temporalis
muscle.
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50. ◦ The maxillary artery (latin: arteria maxillaris) is the largest
terminal branch of the external carotid artery that arises at the
back of the neck of mandible.
◦ The maxillary artery supplies deep structures of the face, such
as the mandible, maxilla, teeth, muscles of mastication, palate,
nose and part of the cranial dura mater.
◦ At its origin, the maxillary artery is embedded in the parotid
gland. Then it runs through the infratemporal fossa and via the
pterygomaxillary fissure enters the pterygopalatine fossa, where
the maxillary artery divides into four branches, and gives off
several side branches.
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MAXILLARY ARTERY

51. ◦ Topographically the maxillary artery can be divided into
three parts: mandibular, pterygoid and pterygopalatine.
◦ From the mandibular part the maxillary artery gives off
five branches:
• Deep auricular artery,
• Anterior tympanic artery,
• Middle meningeal artery,
• Accessory meningeal artery,
• Inferior alveolar artery.
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52. ◦ All these branches of the maxillary artery enter and
supply bones of the skull.
◦ The pterygoid part of the maxillary artery gives off four
branches:
• Deep temporal artery,
• Pterygoid artery,
• Masseteric artery,
• Buccal artery.
◦ These branches supply the corresponding muscles.
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53. ◦ The pterygopalatine part of the maxillary artery provides
four branches that accompany similarly named branches of
the maxillary nerve. These branches include:
• Posterior superior alveolar artery,
• Infraorbital artery,
• Descending palatine artery,
• Sphenopalatine artery.
• The branches of the maxillary artery that feed the teeth
directly are the inferior alveolar artery and the superior
alveolar arteries
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56. INFERIOR ALVEOLAR ARTERY
◦ The inferior alveolar artery branches from the maxillary
artery medial to the ramus of the mandible.
◦ Protected by the sphenomandibular ligament, it gives off
the mylohyoid branch, which rests in the mylohyoid groove
of the mandible and continues along on the medial side
under the mylohyoid line.
◦ After giving off the mylohyoid branch, it immediately
enters the mandibular foramen and continues downward
and forward through the mandibular canal, giving off
branches to the premolar and molar teeth.
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57. ◦ In the vicinity of the mental foramen, it divides into a
mental and an incisive branch.
◦ The mental branch passes through the mental foramen to
supply the tissues of the chin and to anastomose with the
inferior labial and submental arteries.
◦ The incisive branch continues forward in the bone to
supply the anterior teeth and bone and to anastomose with
those of the opposite side.
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58. ◦ The anastomosis of the mental and incisive branches furnishes
a good collateral blood supply for the mandible and teeth.
◦ In their canals, the inferior alveolar and incisive arteries give
off dental branches to the individual tooth roots for the supply
of the pulp and periodontal membrane at the root apex.
◦ Other branches enter the interdental septa, supply bone and
adjacent periodontal membrane, and terminate in the gingiva.
Numerous small anastomoses connect these vessels with those
supplying the neighbouring alveolar mucosa.
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59. SUPERIOR ALVEOLAR ARTERIES
◦ THE POSTERIOR SUPERIOR ALVEOLAR ARTERY
branches from the maxillary artery superior to the maxillary
tuberosity to enter the alveolar canals along with the
posterior superior alveolar nerves.
◦ It supplies the maxillary teeth, alveolar bone, and membrane
of the sinus.
◦ A branch of variable size runs forward on the periosteum at
the junction of the alveolar process and maxillary body
supplying the gingiva, alveolar mucosa, and cheek. When it
is large, it may supplant in part the buccal artery
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60. ◦ A MIDDLE SUPERIOR ALVEOLAR ARTERY is usually
given off by the infraorbital continuation of the maxillary
artery somewhere along the infraorbital groove or canal.
◦ It runs downward between the sinus mucosa and bone or in
canals in the bone and joins the posterior and anterior
alveolar vessels.
◦ Its main distribution is to the maxillary premolar teeth.
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61. ◦ ANTERIOR SUPERIOR ALVEOLAR ARTERY arise
from the infraorbital artery just before this vessel leaves its
foramen.
◦ They course down the anterior aspect of the maxilla in
bony canals to supply the maxillary anterior teeth and their
supporting tissues and to join the middle and posterior
superior alveolar branches in completing an anastomotic
plexus.
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62. DESCENDING PALATINE AND
SPHENOPALATINE ARTERIES
◦ The palatal blood supply comes from two sources but
chiefly from the descending palatine artery, which descends
from its origin from the maxillary through the greater canal.
◦ Its greater palatine branch enters the palate through the
greater palatine foramen and runs forward with its
accompanying vein and nerve in a groove at the junction of
the palatine and alveolar processes.
◦ It is distributed to the bone, glands, and mucosa of the hard
palate and to the bone and mucosa of the alveolar process,
in which it forms anastomoses with fine branches of the
superior alveolaris.
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63. ◦ Minor branches of the descending palatine artery pass to
the soft palate through lesser palatine foramina in the
palatine bone.
◦ The nasopalatine branch of the sphenopalatine artery
courses obliquely forward and downward on the septum
and enters the palate through the incisive canal. It has a
limited distribution to the incisive papilla and adjacent
palate and forms an anastomosis with the greater palatine.
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64. VENOUS DRAINAGE
The venous drainage of the palate and the floor of the oral
cavity occurs through the:
◦ Greater and lesser palatine veins
◦ Sphenopalatine vein
◦ Lingual vein
◦ Submental vein and
◦ Pharyngeal plexus
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65. The venous drainage of the maxilla occurs through:
◦ Anterior superior alveolar vein
◦ Middle superior alveolar vein
◦ Posterior superior alveolar vein
The venous drainage of the mandible occurs through:
◦ Superior alveolar vein and
◦ Inferior alveolar vein
◦ They in turn drain into pterygoid plexus, which is present
between temporalis and lateral pterygoid muscle.
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66. ◦ This plexus communicates with the anterior facial vein and
also communicates with cavernous sinus via foramen ovale
and foramen lacerum.
Clinical relevance-
◦ Hence, due to it communication the superficial face
infection may spread to the cavernous sinus and cause
cavernous sinus thrombosis.
◦ Complications may include edema of the eyelids,
conjunctivae of the eyes, and subsequent paralysis of
cranial nerves which course through the cavernous sinus.
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67. ◦ The pterygoid plexus of veins becomes the maxillary vein.
◦ The maxillary vein and the superficial temporal vein later
join to become the retromandibular vein.
◦ The posterior branch of the retromandibular vein and
posterior auricular vein then form the external jugular vein,
which empties into the subclavian vein.
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69. CLINICAL RELEVANCE
◦ Haematoma:
◦ It is a localized bleeding outside of blood vessels, due to
either disease or trauma including injury or surgery and
may involve blood continuing to seep from broken
capillaries
◦ Inferior alveolar nerve block and Posterior superior
alveolar nerve block
◦ One of the postoperative complication of inferior alveolar
nerve block is haemotoma
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70. ◦ Blood pressure in an artery that has been damaged has to be
high enough for a large hematoma to occur.
◦ Different parts of the maxillary artery can be affected in the
IAN-block, the second division block, the posterior
superior alveolar nerve block and the infraorbital
anaesthesia.
◦ Penetration of the anaesthetics to the orbital area can also
cause temporary blindness and ocular paralysis.
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71. ◦ It is important to learn adequate techniques, anatomical
landmarks and to avoid relocating the needle to different
sides inside the tissue.
◦ Haematoma formation can be avoided by careful aspiration
before injecting the anaesthetic and by gentle removal of
the needle.
◦ Haematomas can be large, they can appear rapidly and be
dramatic in appearance, especially in the infraorbital space.
◦ It is important to inform the patient and re-evaluate the
possibilities of continuing the treatment
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72. ◦ Management of haemotoma:
◦ Treatments include compression of the affected site with
ice packs and antibiotic therapy
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73. REFERENCES
◦ BD Chaurasia’s Human anatomy part 3 6th edition.
◦ Wheeler’s textbook of dental anatomy, physiology and
occlusion 11th edition.
◦ Malamed’s handbook of Local anaesthesia. 6th edition.
◦ SM Balaji textbook of Oral&Maxillofacial surgery.
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