The trigeminal nerve

1. THE TRIGEMINAL NERVE
Aneetinder Kaur
PG 1st year
Conservative Dentistry and
Endodontics

2. CONTENTS
 Introduction
 Trigeminal Nuclei
 Functional Components
 Course & Distribution
 Trigeminal Ganglion
 Divisions of Trigeminal Nerve
 Clinical Examination of V Nerve
 Applied Anatomy
 References

3. INTRODUCTION
 The largest cranial nerve
 It is mixed nerve ( sensory and motor )
 Sensory to – Skin of face
 -Mucosa of cranial viscera
 -Except base of tongue and
pharynx
 Motor to –Muscles of Mastication
 -Tensor vili palatini,Tensor
tympany
 -Anterior belly of digastric
 -Mylohyoid
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

4. NUCLIE

5. NUCLEI
o A cranial nerve nucleus is a collection of neurons (gray matter) in the brain stem that
is associated with one or more cranial nerves.
o Axons carrying information to and from the cranial nerves form a synapse first
at the nuclei.
o Lesions occurring at these nuclei can lead to effects resembling those seen by the
severing of nerve(s) they are associated with.
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

6. SENSORY NUCLIE
Mesencephalic nucleus
•Cell body of Pseudounipolar neuron
•Relay proprioception from muscles of mastication,
Extra ocular Muscles, Facial muscles.
Principal sensory nucleus-
•Relays touch sensation
Spinal nucleus-
•It relays Pain and Temperature
MOTOR NUCLIE
• Innervates muscles of mastication and
tensor tympani and tensor palatini
• Derived from first branchial arch.
• Located in pons medial to principle sensory
nucleus.
MOHIEMS 7TH EDITION

7. FUNCTIONAL COMPONENTS
 Sensory Root
 Motor Root
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

8. SENSORY ROOT
Pain, temperature touch, pressure proprioception
Trigeminal ganglia Bypasses trigeminal ganglia
sensory root.
Spinal
nuclie
Principal sensory
nuclie
Mesencephalic
nuclie
CNS
MOHIEMS 7TH EDITION

9. MOTOR ROOT
Tensor tympani
Tensor palatini
Muscles of mastication
Masseter
Lateral & Medial
Pterygoids
Temporalis
CNS
Motor Nucleus
Motor Root
Mandibular Nerve
9
MOHIEMS 7TH EDITION

10. COURSE & DISTRIBUTION OF THE
ROOTS
Motor root turns inferior with
sensory component of V3 to emerge out
of foramen Ovale as Mandibular nerve.
Ophthalmic and Maxillary division
emerges through Superior orbital fissure
and foramen Rotundum respectively
MOHIEMS 7TH EDITION

11. GANGLION
 SEMILUNAR OR GASSERIAN GANGLION.
 Cresentric in shape with convexity
anterolaterally.
 Contains cell bodies of pseudounipolar neurons.
 LOCATION: lies in a bony fossa at apex of the
petrous temporal bone on floor of middle
cranial fossa, just lateral to posterior part of
lateral wall of the cavernous sinus
 COVERINGS: covered by dural pouch =
MECKLES CAVE or CAVUM TRIGEMINALE.
 cave lined by pia and arachnoid thus the
ganglion is bathed in CSF.
MOHIEMS 7TH EDITION

12. BD CHAURASIA HEAD AND NECK

13. DIVISIONS OF TRIGEMINAL
NERVE

14. DIVISIONS OF TRIGEMINAL NERVE
TRIGEMINAL
NERVE
Ophthalmic
nerve
Carries sensory fibres
from structures derived
from frontonasal process
Maxillary nerve
Conveys afferent fibres
from structures derived
from maxillary process
Mandibular nerve
Carries sensory fibres
derived from
mandibular process
MOHIEMS 7TH EDITION

16. OPTHALMIC NERVE

17. OPHTHALMIC NERVE
 Smallest division.
 Sensory only
 Supplies : eyeballs, conjunctiva,
lacrimal gland, mucosa of nose and
paranasal sinus, skin of forehead
eyelid and nose
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

18. COURSE OF OPHTHALMIC NERVE
emerges from trigeminal ganglion
lateral wall of cavernous sinus
3 branches in ant part of cavernoussinus
lacrimal, nasocilliary, frontal
superior orbital fissure
Orbit

19. LACRIMAL NERVE  Smallest branch
 Passes into orbit through lateral
compartment of the Superior orbital fissure
outside the tendinous ring.
 Sensory to lateral conjunctiva, Upper Lid,
lacrimal gland
 Post synaptic parasympathetic fibers from
pterigopalatine ganglion to lacrimal gland
(parasymathetic secretomotor).
BD CHAURASIA HEAD AND NECK

20. FRONTAL NERVE
 Entersorbit through lateral
partof superiororbital fissure
outside tendinousring
 Passes forward between roof of
orbit and LevatorPalpebral
Superioris
 Divides into supratroclear and
supraorbital branches

21. SUPRATROCHLEAR NERVE
 Smaller nerve
 Medial branch
 Receives communication
branches from infratrochlear
nerve
 Curves around superomedial
margin of orbit
 supplies: median conjunctiva,
Upper Lid and lower part of
forehead
 Lies between frontalis and
corrugator supercilliary
muscles
SUPRAORBITAL NERVE
 Larger nerve
 lateral branch
 Passes through
supraorbital notch
 Divides in medial and lateral
branches.
 Lies beneath frontalis
muscle
 Supplies: conjunctiva,scalp
upto vertex , mucous
membrane of frontal sinus
MOHIEMS 7TH EDITION

22. NASOCILIARY NERVE
 Purely Sensory
 Passes through middle part of superior
orbital fissure within the tendenious
ring.
 Runs along medial wall of orbit
between Superior Oblique and Medial
Rectus
 branches inorbit.
BD CHAURASIA HEAD AND NECK

23. BRANCHES OF CILIARY NERVE
Short Clliary Nerves: Fibers reaches eyeball
and also contains fibers from Cilliary
Ganglion
Long Cilliary Nerves : 2 or 3in no. supply to
Iris and Cornea.
Post Ethmoidal Nerve: passes through
posterior ethmoidal foramen to supply the
Ethmoid and Sphenoid PNS.
Infratrochlear Nerve: appears on face above
med angle the eye. Supplies to skin of
lacrimal sac and caruncle.
MOHIEMS 7TH EDITION

24. ANTERIOR ETHMOIDAL NERVE
larger terminal branch
anterior ethmoidal foramen and canal
goes into anterior cranial fossa on superior surface of
cribriform plate
Enters into the nasal cavity
Medially internal nasal branch is given supplies anterior nasal
septum
laterally internal nasal branch supplies anterior part lateral
nasal cavity emerges as external nasal nerve to skin of
ala,vestibule,and tip of nose
MOHIEMS 7TH EDITION

25. MAXILLARY NERVE

26. MAXILLARY NERVE
 Second division of
trigeminal nerve
 Pure sensory
 Supplies derivatives of
maxillary process and
frontonasal process
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

27. COURSE OF MAXILLARY NERVE
Trigeminal ganglion in
the Middle cranial
fossa
Lateral wall of
cavernous sinus and
through Foramen
rotundum
Into the uppermost
part of Pterigopalatine
fossa
Runs in the groove on
posterior surface of
maxilla
Through inferior
orbital fissure into
orbit as infraorbital
nerve
Through infraorbital
foramen on face
MOHIEMS 7TH EDITION

28. BRANCHES OF MAXILLARY NERVE
IN MIDDLE CRANIAL FOSSA:
- Meningeal branch:
Travels along the middle meningeal artery and provides sensory innervation to cranial
dura matter.

29. IN PTERYGOPALATINE
FOSSA
Ganglionic branches-
Arises as 2trunks.Trunks join to
form single root within
pterygopalatine ganglion. Gives
Orbital branches,Palatine
branches,Pharyngeal
branches,Nasal branches
Gives postganglionic secretomotor fibers
to lacrimal gland via zygomaticotemporal
and lacrimal.
Orbital branch: Supplies periosteum of
orbit
CUNNINGHAM’S MANUAL OF PRACTICAL ANATOMY

30. Nasal branch:
Supplies to mucosa of superior and inferior
conchae, posterior ethmiodal sinus and
posterior portion of nasal septum. It also
includes Nasopalatine branch.
-It passes across roof of nasal cavity
downwards and forwards lying
between mucosa and periosteum of
nasal septum.
-Reaches to floor of nasal cavity and
gives branch to anterior part of nasal
septumand floorof nasal cavity.
-Enters Incisive canal and enters oral
cavity through insicive foramen
-It provides sensation to palatal
mucosa of premaxilla region.

31. . Palatine branch: Arise as greater
palatine (anterior) and lesserpalatine
(middle andposterior)
Greater palatine nerve descends through
pterygopalatine canal from the ganglion
and emerges from greater palatine
foramen of hard palate
-Then moves anteriorly between
mucoperiostem and hard palate upto 1st
premolar supplying sensory innervation to
palatal soft tissue and bone. Then
communicateswith nasopalatine
Middle palatine and posterior palatine
emerges from lesser palatine foramen and
supply soft palate and tonsilar region
respectively.

32. Pharyngeal branch: It leaves the
posterior part of pterygopalatine
ganglion and passes through the
pharyngeal canal It is distributed to
the mucous membrane of thenasal
partof pharynx, posteriorto
eustachian tube.
MOHIEMS 7TH EDITION

33. POST. SUPERIOR ALVEOLAR NERVE
-It arises from the main trunk of maxillary nerve in
the pterygopalatine fossa just before the nerve
enters the inferior orbital canal
Usually arises as 2 trunks.
provide sensory innervation to buccal gingiva in
maxillary molar region and adjacent facial
mucosal surface-2nd trunk enters maxilla through
PSA canal to travel to posterolateral wall of
maxillary sinus providing sensory innervation to
sinus mucosa. Continuing downwards this also
provides sensory innervation to alveoli, PDL, pulp
of molar tooth.

34. ZYGOMATIC NERVE
It enters orbit through infra orbital fissure.

35. A. Zygomaticofacial nerve
-Appears on face through foramen in the
zygomatic bone
-Supplies skin on prominence of
cheek
B.Zygomaticotemporal nerve
-Appears in infratemporal region
through foramen in zygomatic bone
-Supplies skin of temporal region after
piercing temporal fascia 2 cm above zygoma
-Gives communicating branch to lacrimal
Nerve suppling parasymp. Secretomotor fibres
to lacrimal gland.
CUNNINGHAM’S MANUAL OF PRACTICAL ANATOMY

36. IN THE INFRAORBITAL CANAL
Middle superior alveolar
nerve:
runs along lateral wall of maxilla
,Participates in superior dental
plexus Supplies premolars.
Anterior superior alveolar nerve:
Runs in canal in ant wall of maxilla=canalii sinosus
Dental branches
nasal branches

37. Palpebral nerves
pierces Orbicularis Occuli and supplies skin of
lower lid. Nasal branches-supplies skin of
lateral wall nose and septum.
Superior labial nerve
- forms infraorbital plexus
- supplies skin and mucous membrane of
upper lip, cheek and labial glands.

38. MANDIBULAR NERVE

39. MANDIBULAR NERVE
 Largest
 Mixed
Nerve of 1st
branchial arch
Motor root- from motor nucleus in pons
sensory root- gasserian ganglion
exit through foramen ovale in greater wing of
sphenoid
from trunk which remain 2-3 mm undivided
in infratemporal fossa
travels between lat. Pterygoid and Otic
ganglion laterally and tensor palatine
medially anteriorly to med. Meningeal Artery
a small ant.Division and a large post. division
INDERBIR SINGH'S TEXTBOOK OF HUMAN NEUROANATOMY

40. BRANCHES
 Trunk (undivided)
 Nervous Spinosus
 Nerve to medial Pterygoid
 Anterior Division
 Massetric Nerve.
 Deep temporal Nerve.
 Nerve to lateral Pterygoid
 Buccal Nerve.
 Posterior Division
 Auriculo Temporal Nerve
 Inferior. Alveolar Nerve
 Lingual Nerve.

41. BRANCHES FROM TRUNK
Before dividing into anterior and posterior division it gives 2 branches during its 2-3mm path
Nervous spinosus Supplies Dura matter of middle cranial fossa and mastoid air sinus
Nerve to medial Pterygoid Supplies medial pterygoid

42. BRANCHES FROM THE ANTERIOR
DIVISION
The anterior division is significantly smaller
than posterior.
Nerve to lateral pterygoid
Massetric nerve
masseter, also supplies TMJ
Buccal nerve-
Supplies skin and mucous membrane of cheek.
Deep temporal nerve-
There are anterior and posterior deep temporal
nerves. Supply the temporalis.

43. BRANCHES OF POSTERIOR DIVISION
Auriculotemporal nerve-
Arises from 2 roots which run backwards and encircle the middle meningeal artery and
form single trunk ..
divides into
• Auricular branches- supply tragus, upper part of aurical,roof of external auditory meatus,
anterosuperior part of tympanic membrane
• Superficial temporal branches-supply skin of temple
• It also supply sensory and secretomotor to parotid.
• Articular branches-supply the TMJ.

44. INFERIOR ALVEOLAR NERVE
Is mixed nerve
Enters mandible through
mandibular foramen to run in the
mandible
CUNNINGHAM’S MANUAL OF PRACTICALANATOMY

45. BRANCHES OF INFERIOR
ALVEOLAR NERVE
Mylohyoid nerve: Arises just before the nerve enters
mandibular foramen.It pierces the sphenomandibular
ligament along with mylohyoid muscle and runs in the
mylohyoid groove. Supplies to mylohyoid muscle and
anterior belly of digastric.
Mental nerve : It exits canal and divides into three
branches innervating skin of chin and skin and mucous
membrane of the lower lip.
Incisive nerve : It remains within the canal and form plexus
that innervates pulpal tissue of first premolar canine and
incisors through dental branches.
SNELL’S CLINICALANATOMY BY REGION

46. LINGUAL NERVE
lies anterior to inferior
alveolar nerve betweenlateral
pterygoid and tensor palatini
receives chorda tympani (SVA)
Emerges from inferior
border of lateral pterygoid to
lie between ramus and medial
pterygoid in
peterygomandibular space
moves downwards and
forwards deep to
pterygomandibular raphe
between origins of superior
constrictor and mylohyoid
Reach to side of base of
tongue 1 cm below and
behind 3rd molar just below
mucous membrane of lateral
lingual sulcus
Then proceeds
anteriorly
across the
muscles of
tongue ,looping
medially and downwards to
submandibular duct to deep
surface of submandibular
gland where it break in
terminal branches
-Sensory to anterior 2/3 of
tonge along with special
sensation also
sensory to floor of mouth and
gingiva on lingual side of
mandible.

47. GANGLIA ASSOCIATED WITH THE
TRIGEMINAL NERVE
Cilliary Ganglion:
connected with nasocilliary nerve by ganglionic branches in orbit, non synapsing sensory for orbit
Pterygopalatine Ganglion:
connected to maxillary nerve in infratemporal fossa sensory to orbital septum, orbicularis and nasal cavity, max
sinus, palate,nasopharynx.
Otic Ganglion:
between trunk of mandibular nerve and tensor palatini, nerve to medial pterygoid passes through but does not
synapse in the ganglion.
Submandibular Ganglion:
related to lingual nerve, rests on hypoglossus supplies post ganglia Parasym. secretomotor fibres to
submandibular and sublingual gland.

48. CUTANEOUS DISTRIBUTION OF
TRIGEMINAL NERVE
Each half of face is supplied by 13 cutaneous nerves
Of 12 sensory : 11 are from trigeminal nerve and 1
greater auricular nerve
Branches of trigeminal nerve
5 from ophthalmic:
• lacrimal
• supraorbital
• supratrocheal
• infratrochlear
• external nasal
3 from maxillary nerve :
infraorbital nerve
•zygomaticofacial nerve
•zygomaticotemporal nerve
3 from mandibular nerve:
• buccal nerve
• auriculotemporalnerve
• mental nerve
SNELL’S CLINICALANATOMY BY REGION

49. EXAMINATION OF
TRIGEMINAL NERVE

50. SENSORY FUNCTION
use sterile cotton wool and a sharp item on forehead,
cheek, and jaw If any abnormality present we test
the thermal sensation and light touch
CORNEAL REFLEX
clean piece of cotton wool and ask the patient to look
away gently touch the cornea with the cotton wool
and the patient will blink.

51. JAW JERK REFLEX
finger on tip of jaw, grip patellar hammer halfway up shaft and tap finger lightly usually nothing happens, or just
a slight closure.

53. APPLIED ASPECT

54. TRIGEMINAL NEURALGIA
Trigeminal Neuralgia : ‘sudden, usually unilateral, severe, brief, stabbing, recurrent
episodes of pain in the distribution of one or more branches of the trigeminal nerve.
The International Association for the Study ofPain
Painful unilateral affliction of the face, characterized by brief electric
shock like pain limited to the distribution of one or more divisions of the trigeminal
nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking,
talking, and brushing the teeth, but may also occur spontaneously. The pain is abrupt
in onset and termination and may remit for varying periods.
Indian Headache Society

55. INCIDENCE
(Katusik et al., 1990 ;
Rothman and Monson,
1973).
(Penman, 1968).
Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. 2007;334:201-20

56. Joffroy A, Levivier M, Massager N. Trigeminal neuralgia Pathophysiology and treatment. Acta neurol. belg., 2001, 101, 20-2
ETIOLOGY
Dental
pathosis- loss
of teeth and
degeneration
of nerve.
Allergic
Mechanical
factors
Anomalies of
superior
cerebellar
artery
Secondary
lesion

57. Compression leads- demyelination of large myelinated fibres(
does not carry pain)
Demylinated – hyperexcitable
Convey tactile stimuli when electrically coupled with small
Convey tactile stimuli when electrically coupled with small
unmyelinated fibres in close proximity
Ectopic action potential generated in the pain sensitive
afferent fibres of 5th cranial nerve – produce symptoms
PATHOPHYSIOLOGY
Nurmikko TJ, Eldridge PR, Trigeminal neuralgia- pathophysiology, diagnosis and current treatment. Br J Anaesth 2001; 87: 117-
32.

58. TYPES OF TRIGEMINAL NEURALGIA
Classical Trigeminal Neuralgia
Symptomatic Trigeminal Neuralgia
Atypical Trigeminal Neuralgia
Pre- Trigeminal Neuralgia
Multiple Sclerosis Related Trigeminal Neuralgia
Failed Trigeminal Neuralgia

59. CLINICAL FEATURES
•Age of occurrence- late middle age. Female predilection.
•Usually unilateral can be bilateral.
•Predilection for right side
•Sudden, intermittent paroxysmal, sharp, shooting,
lancinating, shock like pain, elicited by slight touch – trigger
points- which radiates from that point, across the
distribution of one or more branches.
•Maxillary > Mandibular > Ophthalmic
•Pain rarely crosses midline.
• Lasts for few seconds but recur at variable frequency.
•During attack: patient grimaces with pain, clutches his hands
over the affected side of face, stopping all the activities and
holds or rubs face, which may redden or eyes may be filled
with tears until the attack subsides
•Attacks do not occur during sleep

61. TRIGGER POINTS AND FACTORS
V2- skin of upper lip, ala, cheeks & upper gums
V3- lower lip, teeth or gums of lower jaw
V1- supraorbital ridge of
affected side
washing the
face
brushing
teeth
shaving
applying
make up
going out in
cold wind
vibrations
from walking

62. WHITE AND SWEET DIAGNOSTIC
CRITERIA FOR TRIGEMINAL
NEURALGIA
Pain-
paroxysmal
Pain-
provoked by
light touch to
trigger
zones
Pain-
confined to
trigeminal
distribution
Pain-
unilateral
Clinical
sensory
examination-
normal

63. INVESTIGATIONS
1. Well taken history
2. Classic clinical pattern
3. Diagnostic nerve blocks
4. Response to treatment with carbamazepine – universal in TN.
5. MRI
Zakrzewska JM, McMillan R. Trigeminal Neura;gia: the diagnosis and management of this excruciating and poorly understood facial
pain.Postgrad Med J 2011;87:410 - 416

64. DIFFRENTIAL DIAGNOSIS
Cluster headache
Dental pain
Glossopharangeal neuralgia
Migraine
Otitis media
Paroxysmal hemicrania
Postherpetic neuralgia
Sinusitis
Tmj syndrome
Trigeminal neuropathy
Rudolph M. KRAFFT, MD, Northeastern Ohio Universities College O
Medicine, Rootstown, Ohio
Am Fam Physician. 2008 May 1;77(9):1291-1296.

65. TREATMENT

66. PHARMACOLOGICAL MANAGEMENT
•Carbamezepine
•Oxcarbamezepine
•Phenytoin
•Pregabalin
•Gabapentin
•Topiramate
•Levitractam
•Valproic acid
•Baclofen
•Clonazepam
•Sodium valproate
•Lamotrigine

67. SURGICAL MANAGEMENT
Peripheral injections
Peripheral neurectomy
Cryotherapy
Peripheral radiofrequency
Neurolysis(thermocoagulation)
Gasserian ganglion ablation procedures

68. SURGICAL MANAGEMENT
Zakrzewska JM, McMillan R. Trigeminal Neura;gia: the diagnosis and management of this excruciating and poorly understood facial
pain.Postgrad Med J 2011;87:410 - 416

69. CONCLUSION
• Since Trigeminal nerve is a mixed nerve, supplying the head and neck
region.
As a dental specialist one should throughly know about the and distribution
of Trigeminal nerve,to properly diagnose the pathologies associated with
Trigeminal nerve and for appropriate treatment planning for any patient .

70. REFERNCES

71. REFERENCES
•Inderbir Singh's Textbook Of Human Neuroanatomy
•BD Chaurasia Human Anatomy Volume 3
•Snell’s Clinical Anatomy By Region
•Cunningham’s Manual Of Practical Anatomy
• Gray’s Anatomy
• Monhiems Local anesthesia and pain control in dental practice
• Harrisson Text Of Internal Medicine
Textbook of Local Anesthesia-Stanley F Malamed

72. • Greenberg, Glick.,BURKETS Oral Medicine 12th Edition: 2012, CBS Publishers
• Laskin MD, strauss RA. Oral and maxillofacial surgery clinics. 2003
• Textbook of Oral & Maxillofacial Surgery by Neelima Anil Malik, 2 nd Edition 2008,
Jaypee Publishers
• Pereira EAC. Trigeminal Neuralgia-Divided but Not Classified.Anesth Pain.
2012;2(2):101-2
• Zakrzewska JM, McMillan R. Postgrad Med J 2011;87:410 – 416
• Nurmikko TJ, Eldridge PR, Trigeminal neuralgia- pathophysiology, diagnosis and
current treatment. Br J Anaesth 2001; 87: 117- 32.
• Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ.
2007;334:201-20
• Bick, S. K. B., & Eskandar, E. N. (2017). Surgical Treatment of Trigeminal Neuralgia.
Neurosurgery Clinics of North America, 28(3), 429–438.
doi:10.1016/j.nec.2017.02.009 url to share this paper: sci-
hub.se/10.1016/j.nec.2017.02.009 Sci-Hub is a project to make knowledge free.
support → updates on twitter created by
RUDOLPH M. KRAFFT, MD, Northeastern Ohio Universities College of Medicine,
Rootstown, Ohio
Am Fam Physician. 2008 May 1;77(9):1291-1296.