GOOD AFTERNOON

TRIGEMINAL NERVE

BY
Dr Sanskriti Gandhi
1st year OMFS
 Nerve
• A nerve is an enclosed, cable-like bundle of peripheral axons (the long,
slender projections of neurons).

• A nerve provides a common pathway for the electrochemical nerve

impulses that are transmitted along each of the axons. Nerves are found
only in the peripheral nervous system.
Nerves can be categorized into :
• Based on the direction that signals are conducted:
1. Afferent nerves.
2. Efferent nerves.
3. Mixed nerves.
• Based on where they connect to the central nervous system:
1. Spinal nerves.
2. Cranial nerves.

• Based on whether they are:

1. Mylinated.
2. Non-mylinated.
Parts of a nerve
 Trigeminal nerve
• Largest.
• Great sensory nerve of the head and
face, and the motor nerve of the muscles
of mastication.

• Origin: From the side of the pons, near its

upper border, by a small motor root and a
large sensory root—the former being
situated in front of and medial to the latter
.
 It is attached to the pons by two roots

Motor root sensory root

Motor root

Origin – motar nucleus present in the upper pons

They pass from the pons , along the medial side of the semilunar ganglion and
exit from the foramen ovale.
They join mandibular division below the base of skull.
Supplies : Muscles of mastication.
 SENSORY ROOT

• Fibers arise from the cells of the semilunar ganglion.

• Semilunar ganglion :

1. Crescent shaped with convexity directed forward.

2. Developes from neural crest .
3. Unipolar neurons.
4. Present in Mickel’s cavity.
 Central
• Ganglion has two processes

Peripheral

• Peripheral is formed by V1,V2,V3.

• Central branch are the sensory root of the trigeminal nerve.
• Central branch re-enters
the pons and divides into Ascending fibers

Descending fibers
• Ascending fibers terminate in upper sensory nucleus and
convey – light ,touch , tactile, sense of position &passive
movement.
• Upper sensory nucleus forms the DORSAL
TRIGEMINOTHALAMIC TRACT.
• Spinal nucleus forms the VENTRAL TRIGEMINOTHALAMIC
TRACT.
• It crosses the midline>enters thalamus>forms loose bundles in
medial lemniscus>to the cerebral cortex.
• Carries – pain and temperature sensation.
 Mesenchephalic root of the Trigeminal Nerve

• Afferent fibers helping mortar root.

• Receive proprioeception from TMJ, PDL, mandibular & maxillary teeth ,
hard palate ,stretch receptors in the muscles of mastication.
• The impulses reach the brain through:
1. The main nucleus of the trigeminal nerve.
2. Secondary fibers cross the brain stem to the thalamus .
3. Fibers from the thalamus to the cortex.
 Wallenberg syndrome
• Wallenberg syndrome (also called the lateral medullary syndrome) is a classic
clinical demonstration of the anatomy of the fifth nerve. It provides a useful
summary of essential points about the processing of sensory information by the
trigeminal nerve.
• A stroke usually affects only one side of the body. If a stroke causes loss of
sensation, the deficit will be lateralized to the right side or the left side of the
body. The only exceptions to this rule are certain spinal cord lesions and
the medullary syndromes, of which Wallenberg syndrome is the most famous
example. In Wallenberg syndrome, a stroke causes loss of pain/temperature
sensation from one side of the face and the other side of the body.
• The explanation involves the anatomy of the brainstem. In the medulla, the
ascending spinothalamic tract (which carries pain/temperature information from
the opposite side of the body) is adjacent to the descending spinal tract of the fifth
nerve (which carries pain/temperature information from the same side of the
face). A stroke that cuts off the blood supply to this area (e.g., a clot in the
posterior inferior cerebellar artery) destroys both tracts simultaneously. The result
is loss of pain/temperature sensation (but not touch/position sensation) in a
unique “checkerboard” pattern (ipsilateral face, contralateral body) that is entirely
diagnostic.
 Divisions of the Trigeminal Nerve

1. Ophthalamic nerve
2. Maxillary nerve
3. Mandibular nerve
 Onion Skin Distribution of the Trigeminal Nerve

• Exactly how pain/temperature fibers from the face are distributed to the spinal
trigeminal nucleus has been a subject of considerable controversy. The present
understanding is that all pain/temperature information from all areas of the human body is
represented .Information from the lower extremities is represented in the lumbar cord.
Information from the upper extremities is represented in the thoracic cord. Information from
the neck and the back of the head is represented in the cervical cord. Information from the
face and mouth is represented in the spinal trigeminal nucleus.
• Within the spinal trigeminal nucleus, information is represented in an onion skin fashion. The
lowest levels of the nucleus (in the upper cervical cord and lower medulla) represent
peripheral areas of the face (the scalp, ears and chin). Higher levels (in the upper medulla)
represent more central areas (nose, cheeks, lips). The highest levels (in the pons) represent
the mouth, teeth, and pharyngeal cavity.
 Ophthalamic Nerve

• Smallest .
• It leaves at the anterior medial part of the ganglion and passes forward in
the lateral wall of the cavernous sinus.
• Its fibers are sensory.
• Arises from the anterior medial part of the ganglion.
• In middle cranial fossa it gives out branches to the dura –the nervous
tentorii.
• It has 3 branches :

1. Lacrimal

2. Frontal

3. Nasociliary
 Lacrimal nerve

• Smallest .
• Passes into orbit at lateral angel of the superior orbital fissure and goes
anterolateral direction to the lacrimal gland.
Frontal nerve

• Largest.
• Enters orbit from the superior orbital fissure.
• Divides into:
1. Supraorbital.
2. Supratrochlear.

Supraorbital nerve
•Largest.
•Passes forward to leave from the superior
orbital fissure.
•Supplies: upper eye lid and the forehead
and anterior scalp.
 Supratrochlear nerve

• Smallest.
• Passes towards upper medial angle of the
orbit.
• Supplies upper eyelid and lower portion of
forehead.

Nasocliary nerve

•Enters orbit from the superior orbital fissure

•Gives divisions in :
1.Orbit
2.Nasal cavity
3.Face
 Branches in the orbit

I. The long root of the ciliary ganglion: long or sensory root, course on the eyeball by
means of short ciliary nerve.
II. The long ciliary nerve: 2 or 3 in no, supply iris and cornea.
III. Posterior ethmoid nerve: enters posterior ethmoid canal to supply the posterior
Ethmoid cells and sphenoid sinus.
IV. Anterior ethmoid nerve: nerve continues on the medial wall of the orbit, supplies
anterior ethmoid cells and frontal sinus.

Internal
branches nasal
branches
External nasal
branches
 Internal nasal branches

Medial / septal branches. Lateral branches.

Branches in the nasal cavity:

Terminal branches on the face:
 Ganglion associated with ophthalmic division of
trigeminal nerve(ciliary ganglion)

• Position: Posterior part of the orbital cavity on the lateral side of the
optic nerve, medial to the Rectus lateralis muscle.
• Three roots:
1. Motor/short (preganglionic , parasympathetic) root: The axons course
with the fibers of the oculomotar nerve to the ciliary ganglion. Fibers
synapse with the postganglionic fibers from the short ciliary nerve to
innervate the sphincter pupillae and ciliary muscles.
2. Sensory/long (postganglionic, sympathetic) root: Fibers arise from
nasociliary nerve. They pass the ganglion without synapsing and
supply the dilator muscles in iris.
3. Sympathetic root: Can come from a) nasociliary nerve, b) internal
carotid plexus .Short ciliary nerves arise from the anterior border of the
ganglion to supply the posterior surface of the eyeball. Postganglionc
fibers supply the circular/sphincter muscles to cause constriction of the
pupil. They also supply the dialator muscle fibers which causes the
dilation of the pupil.
 Maxillary nerve

• Purely sensory.
• Course:

• Branches:
a. Branches given off in middle cranial
fossa.
b. Branches in the pterygopalatine
fossa.
c. Branches in infraorbital groove.
d. Branches on the face.
• Branches given off in middle cranial fossa :
• Branches in the pterygopalatine fossa:
a) Zygomatic nerve: i) Zygomaticofacial nerve.
ii) Zygomaticotemporal nerve.

b) Pterygopalatine nerves:
i) Orbital:
ii)Nasal:1)posterior superior lateral nasal .
2)medial/septal branches .
iii)Palatine:1)greater/anterior palatine.
2) middle palatine .
3)posterior palatine.
c) Posterior superior alveolar nerve.
• Branches in infraorbital groove :
a) Middle superior alveolar nerve.
b) Anterior superior alveolar nerve.
• Branches on the face:
a) Inferior palpebral branches.
b) External/lateral nasal branches.
c) Superior labial branches.
 Sphenopalatine Ganglion

• Asoociated with great superficial petrosal nerve.

• Chiefly secretomotar.
• Contains cell bodies for taste.
• The ganglion is stellate , and lies in the pterygopalatine ganglion suspended from
two roots of the maxillary division of trigeminal nerve.
• The sensory fibers pass through the ganglion , where as the parasympathetic
fibers synapse in the ganglion.
Maxillary nerve: A) Terminal branches B) pterygopalatine ganglion
Branches from the Sphenopalatine ganglion:
i. Orbital branches: consists of afferent fibers to the periosteum of the orbit and to the
mucous membrane to posterior ethmoidal cells.
ii. Nasal branches:
Devided into two roots:
a)Posterior superior lateral nerves: nerve innervates posterior parts of the nasal conca.
b)Nasopalatine nerve: it passes downwards and forwards in between the periosteum
and the mucous membrane in the region of vomer bone and continues downward and
forward to reach the nasal cavity. It then descends in the incisal canal to appear in the
anterior part of the hard palate and supply the mucous membrane in the premaxilla.
iii. Palatine branches: these nerves descend in the pterygopalatine fossa and pterygopalatine
canal.It has three roots: greater palatine, middle palatine, posterior palatine.
a)Greater palatine : emerges from the greater palatine foramen of the lateral margin of
the palatine bone , medial to the upper third molar. It then divides into numerous
branches.
b)Middle palatine: Emerges from a small foramen in the medial aspect of the
pyramidal part of the palatine bone.

c)Posterior palatine: Emerges from the lesser foramen posterior and slightly lateral to
the middle palatine nerve . Conveys sensory and secretory fibers to the tonsillar area.

iv)Pharyngeal branches: Conveys sensory and secretory fibers to the nasopharynx.

v) Secretory fibers to the lacrimal gland: Preganglionic fibers arising in the lacrimal
nucleus pass to the geniculate ganglion and then to the sphenopalatine ganlion. From
the sphenopalatine ganglion the parasympathetic and sympathetic fibers pass back to
the maxillary nerve and enter the zygomatic nerve. Then they leave the zygomatic
nerve , to join the lacrimal nerve and then they control its secreation.
 Mandibular division

• Largest division.

• Formed by the union of motar(larger) root and

sensory(smaller) root.
• Sensory root is from the semilunar ganglion where as
the motor roots are from the medulla oblongata.
Branches1)from undivided nerve.
2)from the divided nerve.

From the Undivided nerve:

1)Nervous spinosum: supplies dura and mastoid cells.
2)Nerve to internal pterygoid muscle :tensor palatini and tensor tympani muscles.

From the divided nerve:

1)Anterior division a)branches to external pterygoid muscle : enters the medial side to
supply the nerve.
b)branches to masseter muscle : passes over the external pterygoid to
traverse the mandibular notch to enter the deep side of the masseter muscle.
c)branches to temporal branches:
i)Anterior deep temporal branches :passes upward and
crosses the infratemporal crest of sphenoid bone to enter the deep part of the anterior
portion of muscle.
ii)Posterior deep temporal branches.
d)Buccal nerve: passes downward, anteriorly and laterally between the
two heads of the external pterygoid muscle .
2)Posterior division a)Auriculotemporal nerve
b)Lingual nerve
c)Inferior alveolar nerve

Auriculotemporal nerve
Origin two roots: medial and lateral
They embrace the middle meningeal artery and unite behind the artery just below the
foramen spinosum. The united nerve passes posteriorly deep to the external
pterygoid muscle and then between the sphenomandibular ligament and the neck of
the condyle.It tranverses upper deep part of the parotid gland and then crosses the
posterior root of the zygomatic arch.It passes upwards with the superficial temporal
artery and divisdes into numerous branches.
Communication of the nerve:
i)Two roots of the nerve: From the otic ganglion control secretion from the parotid
gland.
ii)Branches of the postganglionic sympathetic fibers: these vasomotor fibers pass to the
parotid gland.
iii)Branches of the facial nerve
Branches of the auriculotemporal nerve:
i)Parotid branches iii)Auricular branches v)Terminal branches
ii)Articular branches iv)Mental branches
 Lingual nerve
• Smaller of the two terminal branches.
• Passes medially to the external pterygoid muscle and descends in between the
internal pteygoid , the ramus of the mandible and the pteryomandibular space.
• It also gives fibers to inferior alveolar nerve and to the tonsils and mucous
membrane to the posterior part of oral cavity.
• The lingual nerve lies anteriorly and medial to the inferior alveolar nerve.
• It passes deep to reach the side of the base of the tongue below the lateral lingual
sulcus.
• It is separated from the tongue by the alveolingual groove. It then loops below the
submandibular duct.
• Communication of lingual nerve with corda tympani nerve: as the lingual nerve goes
medially to external pterygoid muscle it is joined from behind from the corda
tympani nerve.
• They control the submandibular and sublingual salivary glands.
 Inferior alveolar nerve
• Largest, passes downward on the medial side of the external pterygoid
muscle and medial side of the mandibular ramus.
• In the pterygomandibular space it enters the mandibular foramen and
distributes in the mandibluar body.
• As the nerve reaches the mental foramen it gives out the mental nerve.
• Few fibers re enter the body of the mandible and form incisive
branch .
• Before entering the mandibular canal ,the nerve gives out the
mylohyoid branch.
• This supplies the motar fibers to the mylohyoid muscle and to the
anterior belly of the diagastric muscle.
Mandibular nerve – posterior trunk : anterior view
 Autonomic ganglion associated with the mandibular division of
the trigeminal nervea
Submandibular (submaxillary) ganglion:
Small ovoid body suspended from the lingual nerve above the submandibular salivary gland.
The parasympathetic preganglionc fibers have origin in the superior salivary nucleous in the
medulla which course within the intermediate nerve and form the chorda tympani nerve. They
then enter the ganglion. The postganglionc fibers are short and supply the secretory fibers to
the submandibular gland. Other fibers rejoin the lingual nerve to supply the sublingual gland .
Ganlion also receives postganglionc fibers from the plexus in the external maxillary artery.
Otic ganglion:
Flattened ovoid body located on the medial side of the undivided division of the mandibular
division of the trigeminal neve. Its infront of the middle meningeal artery below the foramen
ovale. It has two roots parasympathetic and sympathetic root.
Parasympathetic preganglionic fibers- Fibers arise in the inferior salivary nucleus. Efferent fibers
pass from the glossopharengial nerve. The lesser superficial petrosal nerve is the
parasympathtic root to the ganglion.
Sympathetic root- its made up of post ganglionic fibers that originated in the superior cervical
sympathetic gangilion and in the plexus on the middle meningial artery. They pass
uninterrupted from the ganglion to the parotid gland
 Trigeminal Neuralgia

Trigeminal Neuralgia is defined as short sharp lancinating or lightning

paroxysmal unilateral pain in the area of trigeminal nerve
distribution.
HISTORY
It was mentioned first in century A.D. in the writings of
Aretaeus
Described by the Arab physician Jurjani in the eleventh century
French surgeon, Nicolaus Andre coined the condition "Tic Douloureux,"
in 1756
TN also has been called Fothergill’s disease
 CAUSES
Infectious agents, including the human herpes simplex virus

Pituitary tumour(adenoma)
Invasion into the cavernous sinus may cause involvement of cranial
nervesIII, IV,V and VI.
Episode of TRIGEMINAL Neuralgia increases when the patient pain theshold
gets lowered some of them are:
1.Stress
2. Exposure to cold wind
3. Brain trauma
4. Inadequate sleep
5. Poisoning with lead or other chemicals
6. Harmonal fluctuation
7. Hyperglycemia
. Certain antibiotics and anesthetic agentRecurrent Trigeminal neuralgia.
Reactivation of trigeminal neuralgia
 Syndromes in trigeminal neuralgia
• Symptoms:
– More common in 50 years.
– May comman in women.
– Disorder runs in families.
– Pain is lancinating, stabbing excruciating, stitching,
periodic.
– For fraction of seconds.
– May be triggered by various reasons like…..
– Each attack usually repeated at short intervals.
– Pain usually unilaterally, commanly right side.
– Usually mand., max division.
 Diagnosis

Treatment and prevention:

1.Carbemazepine
2. Trileptal
3. Phenytoin
4. Baclophen
5. Gabapentin
6. Pimozide
7. Tizanidine hydrochloride
8. Homeopathy
Other drugs include valproate sodium, racemic ketamine, proparacaine
hydrochloride, and topical capsaicin cream.
 Surgical procedures
• Alcohol injection
• Rhizolysis
• Rhizotomies
– Precutaneous balloon compression
– Glycerol injection
– Radiofrequency rhizoyomy
– Stereotactic radiosurgery
– Microvascular decompression
– Peripheral trigeminal nerve blocks, Sectioning, Avulsions
– Severing the nerve
– Microsurgical rhizotomy
– Electroshock therapy
– Posterior fossa microsurgery
– Milli meter waves
– Gamma knife radiosurgery
THANK YOU