Nerve supply of teeth /endodontic courses

NERVE SUPPLY OF TEETH
INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

• NERVE-INTRODUCTION
• TRIGEMINAL NERVE
OPHTHALMIC NERVE
MAXILLARY NERVE
MANDIBULAR NERVE
• CLINICAL CONSIDERATIONS
• CONCLUSION
• REFERENCES
CONTENTS

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.
The Nervous system

• The central nervous system is composed of
(a) The brain (cerebrum, cerebellum, medulla
oblongata) lodged in the cranial cavity
(b) The spinal cord located in the vertebral canal of
the vertebrae.
• It is composed of nerves and groups of the cell bodies
of neurons forming ganglia. Many ganglia are seen
along the spine and are associated with the viscera.
• It provides a brief description of the meninges in which
the cerebrospinal fluid circulates at the surface of the
central nervous system.

Divisions of Nervous system
Nervous system
 CENTRAL NERVOUS SYSTEM
Brain & Spinal cord
 PERIPHERAL NERVOUS SYSTEM
Cranial & Spinal nerves
and their associated ganglia
Autonomic
Nervous
system
Somatic
Nervous
system
Sensory
Divisions
Motor
Divisions
Parasympathetic
N. system
Sympathetic
N. system
Enteric N.
Systemwww.indiandentalacademy.com

The Innervations of Teeth
 Trigeminal Nerve: (CN V) has 2 roots:-
 The larger sensory root immediately enlarges into a swelling
called the trigeminal (semi lunar) ganglion 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

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.
 Just after leaving the skull the motor root unites with the sensory
root of the mandibular division to form a single nerve trunk.

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
Lower root is sometimes named the spinal root of the nerve

SEMILUNAR
GANGLION
•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.
SEMILUNAR GANGLION

•The ganglia are flat and
crescent shaped, their
convexities facing anteriorly and
downward and they measure
approximately
1 x 2 cm.
•Sensory root fibers enter the
concave portion of each crescent
and the three sensory divisions
of the trigeminal nerve exit from
the convexity.viz.,
OPHTHALMIC,
MAXILLARY, AND
MANDIBULAR

Ophthalmic
Maxillary
Mandibular
TRIGEMINAL NERVE IS ASSOCIATED WITH THREE
DIVISIONS AND FOUR GANGLIA

Ciliary ganglion associated with ophthalmic nerve
Sphenopalatine ganglion associated with maxillary
nerve
Optic 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 sources
These filaments are called as ROOTS OF GANGLION.

Mandibular nerve
V III
Trigeminal
ganglion
Ophthalmic nerve V1
Maxillary nerve V2
The innervation of teeth

MAXILLARY NERVE ,N. MAXILLARIS,
SUPERIOR MAXILLARY NERVE
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

Course & relations
Anterior aspect of Pons
( sensory and Motor Root )
Middle Cranial Fossa
Meckel’s cavity ( Trigeminal Ganglion)
Superior orbital
fissure
Ist Division
Ophthalmic
IInd Division
Maxillary
Foramen Rotundum
IIIrd Division
Mandibular
Foramen Ovale
TRIGEMINAL NERVE

Innervations of Teeth
 Maxillary Teeth:
 Anterior superior alveolar nerve: upper incisors and canines (CNV2)
 Middle superior alveolar nerve: upper premolars and the mesio-buccal
root of the maxillary first molar (CNV2)
 Posterior superior alveolar nerve: upper molars except the mesio-buccal
root of the maxillary first molar (CNV2)
 Mandibular Teeth:
 Inferior alveolar nerve: mandibular teeth, gingiva and lower lip
unilaterally (CNV3)
 Lingual nerve: anterior 2/3 of tongue and mucosa of the floor of the
mouth (CNV3)
 Buccal nerve: gingiva on the buccal side of posterior teeth (CNV3)

 The upper parts of the oral cavity, including the
palate and the upper teeth, are innervated by
branches of the maxillary nerve [CN V2];
 The lower parts, including the teeth and oral part of
the tongue, are innervated by branches of the
mandibular nerve [CN V3];

MAXILLARY NERVE
Gasserion Ganglion
Foramen Rotundum
Pterygopalatine Fossa
Infra –Orbital Canal
Infra –Orbital Foramen
Face
Middle Meningeal N.
-Pterigopalatine N
-PosteriorSuperior
Alveolar N
-Zygomatic N
-Inferior palpebral
-External nasal
-Superior labial
Anterior superior alveolar N
Middle superior alveolar N
- Branches and Course -

Course of maxillary nerve

Maxillary Nerve Branches
(within pterigopalatine fossa )
Zygomatic N
Inferior Orbital
Fissure
Zygomatico-
facial
Supplies-
Facial prominence
Of cheek
Supplies-
Skin of temple
Zygomatico-
temporal

Pterygopalatine Nerves
Orbital Nasal Palatine
Continued -
Greater
palatine n.
middle
palatine n.
posterior
palatine n.
Posterior superior Alveolar N.
Posterior
Hard
palate
Soft palate,
Tonsil,uvula
Soft
palate
Maxillary molars ,
buccal mucosa in
molar region maxillary
sinus
Posterior
superior nasal
Posterior
inferior nasal

Maxillary Nerve Branches
( within infraorbital canal )
Middle superior
alveolar nerve
Anterior superior
alveolar nerve
Supplies-
Maxillary Incisors,
canine
Supplies –
Maxillary premolars

The maxillary nerve
Anterior superior
middle superior
posterior superior
superior alveolar
plexus
Denta & peridental
branches

Maxillary Nerve Branches ( on the face )
Inferior
Palpebral
branches
External
nasal
branches
Superior labial
branches
Lower
Eyelid
Upper
Lip,cheekSide of
Nose

- Superior dental plexus -

The maxillary nerve
 The maxillary nerve V2 is
purely sensory.
 It leaves the skull by way of the
foramen rotundum.
 In the pterygopalatine fossa it
gives off a number of branches.
 It enters the inferior orbital
fissure and the infra-orbital
canal as the infraorbital nerve
which supplies the skin of the
cheek and lower eyelid.www.indiandentalacademy.com

The maxillary nerve
 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].

The maxillary nerve
 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.

The maxillary nerve
 The posterior superior
alveolar nerve 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.www.indiandentalacademy.com

The maxillary nerve
 The middle superior alveolar
nerves 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.www.indiandentalacademy.com

The maxillary nerve
The anterior superior
alveolar nerve originates
from the infraorbital nerve in
the infra-orbital canal, passes
through the maxilla in the
anterior wall of the maxillary
sinus, and via the superior
alveolar plexus, supplies the
canine and incisor teeth.

The maxillary nerve
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.
Greater palatine nerve

The maxillary nerve
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

 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.
The mandibular nerve

Branches from the undivided nerve
-Nervous spinosus
-Nerve to Internal Pterygoid Muscle
Branches from the divided nerve
-Anterior division
-Posterior division
Masseteric,
Deep temporal,
Buccinator,
External pterygoid.
Auriculotemporal,
Lingual, and
Inferior alveolar nerves.
BRANCHES OF MANDIBULAR NERVE

MANDIBULAR NERVE
Course & Relations
Gasserion Ganglion
Motor root
Foramen Ovale
Main
trunk
Nerve to medial pterygoid
Anterior
division
Posterior
division
Buccal
Nerve to Masseter
Nerve To Temporalis
Nerve to Lateral
Pterygoid
Auriculo-temporal
Mylohyoid
Nerve
Superficial
temporal
Cutaneous
Mental
Incisive
Lingual
Inferior alveolar
sensory root
Nervous spinosus-

Mandibular nerve
V III

Almost immediately after
passing through the foramen
ovale it breaks up into its
several branches.

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.

The 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.

 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.
Denta & peridental
branches

THE INNERVATION OF SUPPORTING
TISSUES
 Like the teeth, the gingiva are innervated by nerves
that ultimately originate from the trigeminal nerve
[V].
 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 INNERVATION OF SUPPORTING
TISSUES
• 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.www.indiandentalacademy.com

Clinical consideration-
• Knowledge of anatomy of the branches of the
trigeminal nerve is of utmost importance in
administering local anesthesia for oral surgical
procedures
• During placement of preauricular incision, and
during parotid surgeries, there is chance of
damage to the auriculotemporal nerve, that may
cause frey’s syndrome.
• Branches of trigeminal nerve like infraorbital
nerve and mental nerve are to be preserved
during treatment of fractures.

Clinical consideration-
• 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 masticationwww.indiandentalacademy.com

Clinical consideration
• 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.

•Trigeminal neuralgia or 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
TRIGEMINAL NEURALGIA

Prevalence and Incidence
•Advanced age is a major risk factor for trigeminal
neuralgia
•Rarely affects anyone younger than age 50
•More common in women than in men
•Hypertension and multiple sclerosis are also risk
factors
•An estimated one million people worldwide

Initially short, mild attacks, but trigeminal neuralgia can
progress, causing longer, m ore 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 your teeth
Talking
Putting on makeup
Encountering a breeze
Smiling

ETIOLOGY:
It results from damage to the Auriculotemporal nerve. The syndrome usually
follows some surgical operation.
CLINICAL FEATURES:
Flushing and sweating of the involved side of the face
TREATMENT:
Injection –Botulinum toxin ,
Surgical transection of Neve fiber
Auriculo-Temporal Syndrome
(Frey’s syndrome, Gustatory sweating)

Comprehensive
understanding of the
nerve pathway and the
nerve supply to the
various sites of the oral
cavity is essential for the
dentist. It helps in the
diagnosis and treatment
of pain involving the oral
and paraoral structures.

Human Anatomy-Grays 38th edition
Human Anatomy- Chaurasia.B.D 4th edition, 3rd
volume
Local Anesthesia and pain control in dental
practice- Monheims 7th edition
Local Anesthesia- Malamed 3rd edition

Nerve supply of teeth /endodontic courses

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Nerve supply of teeth /endodontic courses