trigeminal nerve

1. Good
Morni
ng

2. A.KIRANMAYE
PG II YEAR
DEPARTMENT OF PERIODONTICS

3. CONTENTS
 Introduction
motor root
Sensory root
Ganglions
Semilunar
Ciliary
Spenopalatine
Otic
Sub-maxillary
Sub-mandibular
 OPHTHALMIC NERVE (V1)
Lacrimal
Frontal
Nasociliary
 MAXILLARY NERVE (V2)
Cranium
middle meningeal nerve
Pterygopalatine fossa
Zygomatic
Sphenopalatine
Poaterior superior alveolar

4. Infraorbital canal
Anterior superior alveolar
Middle superior alveolar
Face
Inferior palpebral
External nasal
Superior labial
 Mandibular nerve
Anterior division
Massetric
Deep temporal
Buccinator
External pterygoid
Posterior division
Auriculotemporal
Lingual
Inferior alveolar
• Trigeminal nerve reflexes
• Trigeminal neuralgia
Introduction
Causes
Diagnosis
Types
Treatment
• Applied aspects

5. INTRODUCTION

7. The trigeminal nerve - three main divisions i.e. the Ophthalmic,
Maxillary & Mandibular nerves.
 It is the largest of the cranial nerves.
 It is the fifth cranial nerve
 It is a mixed nerve.
 Sensory - greater part of the scalp, the teeth, and the oral
and nasal cavities.

9. MOTOR ROOT

10. PONS & MEDULLA - ANTERIOR VIEW
1. Sensory root of
trigeminal nerve.
2. Pons
3. Vestibulocochlear nerve
4. Facial nerve
5. Abducent nerve
6. Medulla oblongata
7. Motor root of trigeminal
nerve
8. Basilar sulcus

11. It supplies the following muscles:
1. Muscles of mastication
2. Mylohyoid
3. Anterior belly of diagastric
4. Tensor tympani
5. Tensor veli palatini

12. TENSOR TYMPANIIMYLOHYOID

13. SENSORY ROOT

14. NUCLEI
Various nuclei
1. Motor nucleus
2. Sensory nucleus
3. Mesencephalic nucleus
4. Spinal nucleus

15. TRIGEMINAL
GANGLION

16. THE TRIGEMINAL GANGLION
SHAPE - cresentic or semilunar
MEDIALLY - Internal Carotid Artery &
cavernous sinus
INFERIORLY - the motor root and the greater
petrosal nerve
APEX - petrous temporal bone and foramen
lacerum.
BLOOD SUPPLY
Internal Carotid Artery & the accessory
meningeal artery which enters through the
foramen ovale.

18. V3 - MANDIBULAR DIVISION
V1 - OPTHALMIC DIVISION
V2 - MAXILLARY DIVISION

19. OPTHALMIC NERVE

21. It supplies the skin of the
forehead & scalp as far back as
the vertex, mucous membrane of
the frontal sinus & pericranium
skin of the
upper eyelid &
lower part of
the forehead

24. MAXILLARY NERVE

27. • The branches of the maxillary nerve can be divided into the
following 4 groups:
1) IN THE CRANIUM: Meningeal
2) IN THE PTERYGOPALATINE FOSSA: Zygomatic, Posterior superior
alveolar, pterygopalatine
3) IN THE INFRA ORBITAL CANAL: Middle superior Alveolar, Anterior
superior alveolar
4) ON THE FACE: Palpebral, nasal, superior labial

28. MENINGEIAL BRANCH

29. • They contain secretomotor
fibres to the lacrimal gland.
• They provide sensory fibres to
the orbital periosteum &
mucous membrane of the nose,
palate & pharynx.
GANGLIONIC BRANCHES

30. perforates the facial surfaces
& supplies the skin over the
zygomatic bone
skin over the anterior
temporal fossa region.
ZYGOMATIC NERVE

32. INFRA ORBITAL NERVE
BRANCHES IN THE INFRAORBITAL CANAL
Middle superior alveolar nerve Anterior superior alveolar nerve
It arises from the Infra orbital nerve &
runs downwards & forwards along the
infraorbital groove along the lateral wall
of the maxillary sinus.
It also arises in the infraorbital canal
near the mid point.It runs inferiorly &
divides into the branches, which supply
the canine & incisors
maxillary premolars & mesiobuccal
root of the first molar teeth.
mucous membrane of the anterior part of
the lateral wall & floor of the nasal cavity.
It ends in the nasal septum

33. Anterior superior
alveolar nerve

34. BRANCHES GIVEN ON THE FACE
NASAL BRANCHES SUPERIOR LABIAL
BRANCHES
PALPEBRAL BRANCHES
SUPPLYING THE SKIN
OVER THE LOWER
EYELID& LATERAL ANGLE
OF THE EYE ALONG WITH
THE ZYGOMATICOFACIAL
& FACIAL NERVES
THEY SUPPLY THE SKIN OF THE
NOSE & TIP OF THE NASAL
SEPTUM & JOIN THE EXTERNAL
NASAL BRANCH OF THE
ANTERIOR ETHMOIDAL NERVE
THEY SUPPLY THE SKIN
OVER THE ANTERIOR
PART OF THE CHEEK &
UPPER LIP INCLUDING
THE MUCOUS
MEMBRANE & LABIAL
GLANDS. THEY ARE
JOINED BY THE FACIAL
NERVE & FORM THE
INFRAORBITAL PLEXUS.

36. SPHENOPALATINEPTERYGOPALATINE
GANGLION
 It is the largest of the
peripheral ganglia.
 It is associated with the greater
petrosal nerve. It acts as a relay
station between the superior
salivatory nucleus in the pons and
the lacrimal gland & mucous &
serous glands of the palate, nose
& paranasal sinuses.

37. The branches of the Pterygopalatine ganglion are:-
I. Orbital branches:
II.Palatine branches:
1.Greater palatine
2. Lesser palatine
3.Posterior palatine
III.Nasal branches:
1.Posterior superior lateral
2.Nasopalatine/Sphenopalatine
IV.Pharyngeal branch:

38. 1. Orbital branches:
They are made up of afferent fibres & convey sensory
impulses from the periosteum of the orbit. Others supply
the mucous membrane of the Posterior ethmoidal &
sphenoidal air cells.
2. Palatine branches:
They are distributed to the roof of the mouth, soft palate,
tonsil & lining membrane of the nasal cavity.

39. PALATINE BRANCHES
POSTERIOR PALATINE NERVEGREATER PALATINE NERVE LESSER PALATINE NERVE
IT EMERGES FROM THE
FORAMEN MEDIAL TO THE
3 RD MOLAR, CONTINUES
FORWARD SPLITTING INTO
NUMBER OF BRANCHES. IT
IS SENSORY TO THE
MUCOSA OF THE HARD
PALATE & PALATAL
GINGIVA.
THIS NERVE EMERGES
FROM A SMALL FORAMEN
IN THE MEDIAL ASPECT OF
THE PYRAMIDAL PART OF
THE PALATINE BONE.
SENSORY SUPPLY IS TO THE
MUCOUS MEMBRANE OF
THE SOFT PALATE
IT EMERGES FROM A
FORAMEN SLIGHTLY
LATERAL TO THE MEDIAN
PALATINE NERVE. IT
CONTAINS SENSORY &
SECRETOMOTOR FIBRES TO
THE MUCOUS MEMBRANE
OF THE TONSILLAR AREA.

41. NASAL BRANCHES
NASOPALATINE
(SPHENOPALATINE)
NERVE
POSTERIOR SUPERIOR
LATERAL NERVES
THEY SUPPLY THE
POSTERIOR PART OF
THE NASAL CONCHAE
IT PASSES DOWNWARDS & FORWARDS BETWEEN
THE PERIOSTEUM &MUCOUS MEMBRANE IN THE
REGION OF THE VOMER, CONTINUES DOWNWARDS
& FORWARDS, REACHS THE FLOOR OF THE NASAL
CAVITY.DESCENDS INTO THE INCISAL CANAL TO
APPEAR IN THE ANTERIOR PART OF THE HARD
PALATE & SUPPLIES THE MUCOUS MEMBRANE OF
THE PREMAXILLA.

42. 4.PHARYNGEAL BRANCHES:
This branch supplies sensory & secretory fibers to the mucous
membrane of the nasopharynx. It arises from passes through the
palatovaginal canal along with the pharyngeal branch of the maxillary
artery.

44. MANDIBULAR NERVE

46. BRANCHES OF THE DIVIDED NERVE
I. Anterior division

47. • Passes laterally above the
lateral pterygoid in front of
the TMJ & behind the
tendon of temporalis.
• It passes through the
mandibular notch to sink
into the masseter muscle.
• It also gives a branch to the
TMJ.
THE MASSETRIC NERVE

49. POSTERIOR DIVISION
1.The Auriculotemporal nerve: Course of the nerve
• Arises by a medial & lateral roots, that
encircle the Middle Meningeal Artery &
unite behind it just below the foramen
spinosum.
• The united nerve passes backwards, deep
to the lateral pterygoid muscle & passes
between the sphenomandibular ligament &
the neck of the condyle.
• It then passes laterally behind the TMJ i.r.t.
to the upper part of the parotid. It emerges
from behind the TMJ, ascends posterior to
the superficial temporal vessels & crosses
the posterior root of the zygomatic arch.

50. Branches of the Auriculotemporal nerve:
1. Parotid branches-----secretomotor, vasomotor.
2. Articular branches--- to the TMJ.
3. Auricular branches---to the skin of the helix & tragus.
4. Meatal branches----- Meatus of the tymphanic
membrane
5. Terminal branches----Scalp over the temporal region

52. LINGUAL NERVE
It gives off sensory fibres to the tonsil &
the mucous membrane of the posterior
part of the oral cavity.

53. Communication of the facial nerve (Chorda tympani) with the
lingual nerve.
As the lingual nerve passes medially to the lateral
pterygoid, it is joined from behind by the chorda tympani. This
nerve conveys secretory fibres from the facial nerve. The
parasympathetic secretory fibres control the submandibular &
sublingual salivary glands.

55. INFERIOR ALVEOLAR NERVE
• The nerve descends deep to the
lateral pterygoid muscle at the
lower border of the muscle, it
passes b/n the sphenomandibular
ligament & the ramus to enter the
mandibular foramen.
• From here the nerve runs in the
canal giving of branches to the
mandibular teeth as apical fibres
& enters the apical foramina of
the teeth to supply mainly the
pulp as well as the periodontium.

57. APPLIED ANATOMY

58. JOHN LOCKE in 1677 gave the first full description with its
treatment.
NICHOLAS ANDRE in 1756 coined the term “tic doloureux”
JOHN FOTHERGILL in 1773 published detailed description of tn ,
since then , it has been referred to as “fothergill’s disease”.
TRIGEMINAL NEURALGIA
INTRODUCTION

59. • Incidence- 1:25000, slight female predominance, greater than
50yrs
• Attacks more common in 2nd and 3rd divisions
• Right side more often than left side
• Chronic disorder

60. Definition:
A unilateral disorder of the face characterized by brief electric
shock like pain limited to the distribution of one or more divisions of
the trigeminal nerve

61.  Cause not known.
 Benign tumours and vascular anamolies compressed trigeminal
nerve root.
ETIOLOGY

62. TRIGGER ZONES
• Area of facial skin or oral mucosa
• Low intensity mechanical stimulation—elicit a
typical pain attack
• Few mm in size
• Exclusively peri-oral region
• 1st division rare

63. SWEET DIAGNOSTIC CRITERIA
1. The pain is paroxysmal.
2. The pain may be provoked by light
touch to the face.
3. The pain is confined to the trigeminal
distribution.
4. The pain is unilateral.
5. The clinical sensory examination is
normal.

64. TREATMENT

65. AURICULOTEMPORAL SYNDROME [FREYS SYNDROME]
 Uncommon condition typically affecting Auriculotemporal nerve
 Etiology : Surgical removal of parotid gland
parotitis
Ramus resection
Clinical features : Gustatory sweating
Flushing One side of face involved
Facial redness

66. Treatment:
• Medications - Include carbamazepine , phenytoin,
gabapentin and baclophen
• The surgical procedures then considered are microvascular
decompression surgery.

67. Maxillofacial trauma
Infraorbital nerve
Zygomatico orbital nerve
 Mandibular angle and body fractures.
Inferior alveolar nerve
Lingual nerve
Maxillary and mid facial fractures.
Palatine nerves are affected
NERVE INJURIES

68. INJURIES TO NERVES DURING SURGICAL PROCEDURES
Orthognathic surgery
• Sagital osteotomies.
• Bilateral splitosteotomies.
These surgeries result in injury to inferior alveolar nerve.
Genioplasty.
• Mental nerve is injured.
Third molar extraction.
• Inferior alveolar and lingual nerve are injured.
Implant placement.
• Inferior alveolar and lingual nerve are most commonly affected.

69. Leprous Neuropathy
INFECTIOUS DISEASES AFFECTING TRIGEMINAL NERVE
Neuro syphilis
Herpes Zoster

70. It occurs when the trigeminal nerve is damaged by surgery or physical
trauma in such a way that the feeling sensation in part of the face is
reduced or eliminated entirely while the sense of pain remains.
ANAESTHESIA DOLOROSA

71. CAUSES
anaesthesia dolorosa is caused by injury to the trigeminal nerve or as a
complication of surgery to correct a condition such as trigeminal neuralgia . It can
occur after
glycerol injection
 alcohol injection
 partial nerve sections
radiofrequency rhizotomy
gamma knife surgery
balloon compressions and
 microvascular decompression.

72. • The pain is usually burning, pulling or stabbing but can also include
a sharp, stinging, shooting or electrical component.
• Pressure and "heaviness" can also be part of the pain symptoms.
Often there is eye pain.
• Cold increases the feeling of numbness sometimes making the face
feel frozen.
• facial numbness
SYMPTOMS

73. In the past, diagnosis of anaesthesia dolorosa was based on symptoms. More
recently, thermograms ( a test that measures minute temperature differences in
the painful area) and nerve blocks of the sympathetic nervous system are
sometimes used in diagnosis.
TREATMENTS
No single treatment has been found yet that resolves all of the pain. However
there are a number of treatment options that can help to manage the pain and
discomfort
DIAGNOSIS

78. Balloon Compression Rhizotomy