short description on fifth cranial nerve with its importance

1. 1

3. Introduction
Nomenclature
Development
Basic component
Functional component
Nucleus of trigeminal
Ganglions of trigeminal
Trigeminal ganglion
Divisions of trigeminal nv
 Opthalmic branch
 Ciliary ganglion
 Maxillary branch & associated ganglion
 Mandibular branch & associated ganglion
3

4. Trigeminal pathway
Commonest clinical applications
Clinical implication of
 Trigeminal ganglion
 Opthalmic division
 Maxillary division
 Mandibular division
Lesion associated with intracranial part of
trigeminal nerve
Frey’s syndrome
Paratrigeminal syndrome
conclusion
4

5. It is the 5th cranial
nerve
Largest cranial nerve
It is the main
sensory nerve of the
face and head
It was described by
Fallopius & Meckle in
1748
5

6. As this nerve has
three identical
peripheral branches
so that called as
trigeminal nerve
“Tri-Geminus”
means thrice
twinned
This term is coined
by Winslow.
6

7. It is derived from 1st branchial arch
So that the structures derived from the 1st
branchial arch are innervated by this nerve.
The trigeminal nerve contains both sensory and
motor components.
The somata of, motor neuroblasts originate
with in neuroepithelium,
sensory neuroblasts --- derived from the neural
crest and from ectodermal placodes.
7

8. This three roots are basically sensory by nature
Along with this sensory branch their is a motor
root of this trigeminal nerve
It is mixed nerve.
Contains 170,000 sensory fibres
7,700 motor fibres
The 3 divisions have approx ophthalmic 26,000
maxillary 50,000
mandibular 78,000
8

9. 2 Roots:
Larger Sensory Root
Smaller Motor Root
3 primary divisions:
Ophthalmic ( V1) - sensory
- innervates the upper portion of the face
Maxillary (V2)- sensory – innervates the mid face
region
Mandibular (V3) -sensory+motor – innervates the
lower facial region
9

10. 10

11. Sensory nuclei
Motor nucleus
11

12. Main sensory nuclei
Bulbospinal nuclei
Mesenchephalic nuclei
12

13. lies in pons lat to motor nucleus
relays discriminitive touch
13
continuous superiorly with main
sensory nucleus and extends
inferiorly through medulla
oblongata and into upper part
of spinal cord as far as second
cervical segment.
where its continuous with
sub.Gelatinosa.

14. PARS ORALIS
 associated with the
transmission of discriminative
(fine) tactile sense from the
orofacial region
PARS INTERPOLARIS
 associated with the
transmission of tactile sense,
as well as dental pain
PARS CAUDALIS
 associated with the
transmission of nociception
and thermal sensations from
the head
14

15. V1 – pars caudalis
V2- pars interpolaris
V3- pars oralis.
15

16. first order sensory
nucleus .
cell body of
pseudounipolar neurons
relay proprioception
from muscles of
mastication, facial
muscles.
forms monosynaptic
reflex arc .
situated in midbrain just
lat to aqueduct
16

17. Innervates muscles
of mastication and
tensor tympani and
tensor palatini
Located in pons
med. to princi sen.
Nucleus
17

18. Semilunar ganglion
Cilliary ganglion
Sphenopalatine ganglion
Otic ganglion
Submaxillary ganglion
18

19. SEMILUNAR OR GASSERIAN GANGLION.
Sensory ganglion corresponding to DRG of spinal
nerves.
Cresentric in shape with convexity anterolat.
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 lat to post. Part of lat wall of the
cavernous sinus.
5 cm deep to the preauricular point
19

20. COVERINGS: covered by dural pouch = MECKLES CAVE
OR CAVUM TRIGEMINALE.
Roof- 2 layers of dura
floor- 1 dural and 1endosteal dural layer.
cave lined by pia and arachnoid thus the
ganglion is bathed in CSF.
ARTERIAL SUPPLY: ganglionic branches of ICA, middle
meningeal artery and accessory meningeal artery.
20

21. RELATIONS:
SUPERIORLY: sup petrosal sinus, free margin of tentorium cerebelli
INFERIORLY: motor root , greater petrosal nerve, petrous apex
foramen lacerum
MEDIALLY: post. Part of lat. Wall of cavernous sinus
ICA with its sympathetic plexus
LATERALLY: uncus of temporal lobe
nervous spinosum.
21

22. Give off minute branches -
tentorium cerebelli and to dura
mater in the middle cranial
fossa.
From its convex border three
large nerves arises
Ophthalmic
Maxillary
Mandibular.
Ophthalmic and Maxillary -
exclusively of sensory fibers.
Mandibular is joined outside
the cranium by the motor root.
22

23. Motor root runs - front and medial to the
sensory root & passes beneath the ganglion.
Leaves the skull - foramen ovale - immediately
below this foramen - joins the mandibular nerve
23

24. Smallest div.
Only sensory
Supplies : cornea,conjuctiva,upper
lid,forehead,ant part of scalp,nose.
Course:
emerges from trigeminal ganglion
lat wall cavernous sinus
3 branches in ant part of cavernous sinus
nasocilliary, frontal, lacrimal
superior orbital fissure
orbit
24

25. Smallest
Passes into orbit through lat
compartment of the sup orbital
fissure outside the tendinous
ring.
Receives communicating branch
from trochlear nerve
Receives branch from
zygomaticotemporal nerve
Passes along sup border of LR
with lacrimal art
Sensory to lat conjunctiva,UL,
lacrimal gland(parasym
secretomotor).
25

26. Largest
Enters through lat part of sup orbital fissure outside tendinous ring
Passes forward between roof of orbit and LPS
Divides midway into SUPRATROCHLEAR NERVE
SUPRAORBITAL NERVE
26

27. SUPRATROCHLEAR N SUPRAORBITAL N
Smaller nerve
Medial
Receives commu
branch from
infratrochlear n
Curves around sup med
margin of orbit
supplies: med
conjunctiva and UL
lower part of forehead
Lies betwn frontalis
and corrugator
supercilli
Larger
Lies lateral
Passes through
supraorbital notch
Lies beneath frontalis
Divides in med and lat
branches.
Supplies: conjunctiva,
scalp upto vertex,
mucous membrane of
frontal sinus
27

28. Sensory only
Passes through med part of sup.
Orbital fissure within the tendenious
ring betwn the two div of
occulomotor nerve.
Crosses from lat to med above Optic
Nerve with ophthalmic art
Runs along med wall of orbit betwn
SO and MR
Divides into terminal branches ANT
ETHMOIDAL NERVE and
INFRATROCHLEAR NERVE
5 branches in orbit.
28

29. 1. Communicating branch to cilliary
ganglion:
passes along short cilliary nerves.
carries symp fibres from IC plexus and
sensory fibres from the eyeball.
2. LONG CILLIARY NERVES : 2 or 3.
run along med side of the ON
pierce sclera and supply cornea, iris,
cilliary body.
carry pain temp and touch.
sympathetic motor supply to
dilator pupillae.
3. POST ETHMOIDAL NERVE:
passes thru post ethmoidal foramen
to supply the ethmoid and sphenoid
PNS.
29

30. 4. INFRATROCHLEAR NERVE:
smaller terminal branch
emerges below trochlea
appears on face above med angle the eye.
supplies: upper half of external nose
skin of med most part of UL andLL
medial conjunctiva
lacrimal sac
caruncle
30

31. 5. ANT ETHMOIDAL NERVE:
larger terminal branch
course: ant ethmoidal foramen and canal
into ant cranial fossa on sup surf of cribriform plate
Through slit lat to crista galli into nasal cavity
Med internal nasal branch lat internal nasal branch
Supplies ant nasal septum supplies ant part lat
nasal cavity emerges as
external nasal nerve to
skin of ala,vestibule,and
tip of nose
31

32. CILIARY GANGLION (Lenticular ganglion)
Situated - back part of the orbit - on the
lateral side of the ophthalmic artery.
Its roots are 3 in number and enter its
posterior border.
Long or Sensory Root (sympathetic root)
-Derived from the nasociliary nerve.
-carries postganglionic fiber from sup.cervical sympathetic
ganglion
- innervate radial fiber of dilator pupillae muscle in iris
Short or Motor Root (parasympathetic root)
- Derived from the branch of the oculomotor nerve
- these preganglionic fiber along with the post ganglionic
fiber form short ciliary nerve which innervate sphinctre pupillae
& ciliary muscle of iris
Sympathetic Root
- fsensory root of nasocilliary nerve
- it causes pupil to dilate
- it causes pupil to constrict
- changes the convexity of lense
32

33. Second division of the trigeminal nerve.
Is a sensory nerve.
It begins - middle of semilunar ganglion as a flattened
plexiform band, passing horizontally forward - leaves the skull
, foramen rotundum.
Then crosses - pterygopalatine fossa - enters the orbit through
the inferior orbital fissure - it traverses the infraorbital groove
and canal in the floor of the orbit and appears on the face -
infraorbital foramen
33

34. 34
Branches of Maxillary Nerve
In the cranium Middle Meningeal Nerve
In the Pterygopalatine
fossa
Zygomatic
Sphenopalatine
Posterior Superior
Alveolar
In the Infraorbital Canal Anterior Superior
Alveolar
Middle Superior Alveolar
On the Face Inferior Palpebral
External Nasal
Superior Labial

35. From middle of the gasserion ganglion it travels
anteriorly & downwards
Branch Within cranium –Middle meningial nerve
Run along with middle meningial artery,
-- sensory innervation to dura matter.
Exit cranium from foramen rotundum
35

36. Zygomatic nerve
 Lies within inferior orbital
fissure
 Give two branches
Zygomaticotemporal
 Supplies skin of temporal
region after peircing temporal
fascia 2 cm above zygoma
 Gives communicating branch
to lacrimal N suppling
parasymp. Secretomotor
fibres to lacrimal gland
Zygomaticofacial
 Supply skin of face
36

37. Two short nerve trunk
Unite with Pterygopalatine ganglion
Triangular or heart-shaped, of a
reddish-gray color.
Situated just below the maxillary
nerve as it crosses the fossa.
It receives a sensory, a motor, and
a sympathetic root.
Redistribute in 4 branches
Orbital
Nasal/ nasopalatine
Palatine
Pharyngeal
37

38. Orbital
 Periosteum of orbit
 Post.ethmoid cells & sphenoid sinus
 Secretory to lacrimal gland
Nasopalatine
Posterior superior lateral nasal branch
 Carry sensation from mucous memb.of nasal septum & post.ethmoid cells
Medial/septal branch
 Mucous membrane on vomer
Nasopalatine
 Come out through incisal canal & supply premaxilla
Palatine
Greater/Anterior palatine
 Emerge from greater palatine foramen
 Carries secretory & sensory fibers to mucous of hard palate & palatal gingivae
Middle palatine
 Emerge from small foramen of pyramidal part of palatine bone
 Supply sensory & secretory fibers to soft palate
Posterior/ Lesser palatine
 Emerge from lesser palatine foramen
 Supply sensory and secretory fibers to tonsillar area
Pharyngeal
Sensory and secretory fibers to nasopharynx
38

39. 1st Trunk
External to bone
Buccal gingiva of maxillary molar
2nd Trunk
Enters into maxilla
Sensory to maxillary sinus,
maxillary molar (except mesio
buccal root of 1st max.molar)
39

40. 40
MSA nerve ASA nerve
1st & 2nd PM region supplies antarior
wall of
Mesiobuccal root of 1st M maxillray sinus &
supplies 1 to 3.
PDL, buccal soft tissue, bone
(in 30% cases, it is absent then
Psa & Asa
Provides its supplies).

41. In the face (emerge through inferior orbital foramen)
Inferior palpebral external nasal sup. Labial
Skin of lower eyelid skin of lateral skin,mucous
aspect of nose memb.,upper
41
lip.

42. Largest
Mixed
Motor root- from motor sensory root- gasserian ganglion
42
nucleus in pons
exit through foramen ovale in grt. Wing of sphenoid
from trunk in infra-temporal fossa
travels between lat. Pterygoid and otic ganglion laterally and
tensor palatine medially anteriorly to med. Meningeal A.
small ant. Division large post. division

43. Trunk
 Nervous spinosus
 N. to med. Pterygoid
Ant. Division
 Massetric N.
 Deep temporal N.
 N. to lat. Pterygoid
 Buccal N.
Post. Division
 Auriculo temporal
 Inf. Alveolar
 Lingual N.
43

44. Nervous spinosus
Through foramen spinosus
Dura mid cranial fossa
Nerve to med. Pterygoid
Supplies medial pterygoid
Through otic ganglion without interruption to
Tensor tympani
Tensor palatini
44

45. Nerve to lat pterygoid
Massetric nerve- lies sup to lat pterygoid,inf to
temporalis tendon and ant to TMJ.
supplies masseter and TMJ
Buccal nerve-is the only sensory branch of ant div.
travels betwn 2 heads of lat pterygoidand emerges
in cheek at ant border of masseter. Supplies skin
and mm of cheek.
Deep temporal nerve -the 2 nerves ascend deep to
lat pterygoid and supply temporalis.
45

46. 1.Auriculotemporal nerve-
Arises from 2 roots which encircle the middle
meningeal art
The trunk passes post to lat pterygoid betwn neck of
mandible and sphenomandibular lig sup to 1st part
of maxillary art.
Lies behind the TMJ close to the parotid
Ascends behind sup temporal vessels and then in
temporal region divides into superficial temporal
branches. 46

47. Branches of auriculotemporal nerve
auricular branches -supply
tragus,upper part of aurical,roof
of ext auditory meatus,anterosup
part of tympanic memb
Superficial temporal branches-supply
skin of temple
Articular branches-supply the
TMJ.
47

48. 2. Inferior alveolar nerve:
Is mixed nerve
Passes between mandible and sphenomandibular lig inf
to lat pterygoid,
Enters mandible through mandibular foramen to run in
a bony canal below the teeth
Branches: to molars and premolars
incisive nerve
mental nerve
mylohyoid nerve-mylohyoid and ant belly
of diagastric
communicating nerve to lingual nerve
48

49. 3.Lingual nerve: lies ant to inf. alveolar n between lat
pterygoid and tensor palatini
receives chorda tympani (SVA)
Emerges from inf border of lat pterygoid to lie betwn ramus
and med pterygoid
Between origins of sup constrictir and mylohyoid
1 cm below and behind 3rd molar in gingiva
Rests on hypoglossus lat to the tongue where it is
related to the submandibular ganglion
Gives sensory supply to presulcal tongue ,floor of mouth,
mandibular gums,and carries proprioception from tongue.
49

50. Branches of lingual nerve and its
communications:
1.Chorda tympani
2.Communications with
submandibular ganglion
3.Hypoglossal nerve
50

51. Submandibular/ Submaxillary
ganglion
Otic ganglion
51

52. SUBMAXILLARY / SUBMANDIBULAR
GANGLION:
Small size & fusiform in shape.
Situated above the deep portion of the
submaxillary / Submandibular gland.
DISTRIBUTION:
Arise - from the lower part of the
ganglion.
Supply - mucous membrane of the mouth
and the duct of the submaxillary gland.
52

53. OTIC GANGLION:
Small, oval shaped,reddish-gray color ganglion
- situated immediately below the foramen ovale.
Lies - medial surface of the mandibular nerve.
DISTRIBUTION:
A filament to the
Tensor tympani.
Tensor veli palatini.
53

54. Responsible for carrying
Pain ,Temperature
Light Touch
discriminative touch
pressure
Utilize the 3-neuron sensory system
Primary neuron
secondary neuron
tertiary neuron
Utilize the contra lateral ventral trigeminothalamic tract
54

55. 55

56. 56

57.  The most commonly anesthetized nerves in dentistry
are branches or nerve trunks associated with the
maxillary and mandibular divisions of the trigeminal
nerve.
 The maxilla’s relatively porous alveolar bone allows
for the use of straightforward local anesthetic
techniques of paraperiosteal field blocks or
infiltrations.
 The mandible is different. The outer layer of cortical
bone is thick and nonporous and thus normally
requires the use of a nerve block at a site away from
the teeth being treated.
57

58. Techniques of Maxillary Regional
Anesthesia
The techniques most commonly employed in maxillary
anesthesia include
• Supraperiosteal (local) infiltration
• Periodontal ligament (intraligamentary) injection
• Posterior superior alveolar nerve block
• Middle superior alveolar nerve block
• Anterior superior alveolar nerve block
• Greater palatine nerve block
• Nasopalatine nerve block
• Local infiltration of the palate
• Intrapulpal injection
58

59. 59

60. 60

61. Inferior alveolar nerve block
Lingual nerve block
Mental nerve block
PDL infiltration
Local infiltration (occasionally)
61

62. 62

63. Shingles and varicella-zoster: The trigeminal
ganglion, as any sensory ganglion, may be the site
of infection by the herpes zoster virus causing
shingles, a painful vesicular eruption in the sensory
distribution of the nerve.
Trigeminal neuralgia (tic douloureux): This is severe
pain in the distribution of the trigeminal nerve or
one of its branches, the cause often being
unknown. It may require partial destruction of the
ganglion.
63

64. Ethmoid tumours
Malignant tumours of the mucous lining of the
ethmoid air cells may expand into the orbits,
damaging branches of opthalmic nerve. This
may lead to displacement of the orbital
contents causing proptosis and squint, and
sensory loss over the anterior nasal skin.
Nasal fractures
Trauma to the nose may damage the nasociliary
nerve. Sensory loss of the skin down to the tip
of the nose may result.
64

65. Corneal reflex: When the cornea is touched, usually
with a wisp of cotton, the subject blinks. This tests
V and VII. The nerve impulses pass through cornea
and then through nasociliary nerve to the brain.
Supraorbital injuries
Trauma to the supraorbital margin may damage the
supraorbital and supratrochlear nerves causing
sensory loss in the scalp.
65

66. Infraorbital injuries (malar fractures):
Trauma to infraorbital margin may cause sensory loss
of infraorbital skin.
Maxillary antrum tumours:
Malignant tumors of the mucous lining of the
maxillary antrum may expand into the orbit,
damaging branches of maxillary nerve, particularly
the infraorbital. This may lead to anaesthesia over
the facial skin.
66

67. Maxillary sinus infections: Infections of the
maxillary sinus may cause infraorbital pain or may
cause referred pain to other structures supplied by
maxillary nerve e.g. upper teeth.
Maxillary teeth abscesses: The roots of the
maxillary teeth (especially the second molars) are
intimately related to the maxillary sinus. Root
abscesses are painful.
67

68. Lingual nerve: Careless
extractions of the third
lower molar, abscesses of
its root, or fractures of
the angle of the mandible
may all damage the lingual
nerve. This may result in
loss of somatic sensation
from the anterior portion
of the tongue and loss of
taste sensation.
Protection of lingual nerve::
during surgical removal of
mandibular third molar-
68

69. Inferior alveolar nerve: Trauma to the
mandible may damage or tear
the inferior alveolar nerve in the
mandibular canal leading to
sensory loss distal to the lesion.
69

70. Mumps: Mumps is inflammation of the parotid
gland causing tension in the parotid capsule which
is innervated by the auriculotemporal nerve. It
gives both local tenderness and referred ear ache.
Submandibular duct: The intimate relationship between the
submandibular duct and the lingual nerve is significant in duct infections
and surgery. If the lingual nerve were damaged during a submandibular
surgery, there would be sensory loss, both somatic and taste, in the
anterior portion of the tongue.
70

71. Referred pain to the ear: Disease of the TMJ or
swelling of the parotid gland may cause ear ache
because of referred pain. Also, pain from the lower
teeth, oral cavity and tongue may be referred to
the ear.
Superficial temporal artery biopsy: The auriculotemporal
nerve accompanies the superficial temporal artery on the temple. In cases
of temporal arteritis, the nerve is anaesthetized so that the overlying skin
can be incised to obtain a biopsy of the artery.
71

72. Infections and neoplasia most commonly involve
the peripheral divisions of the trigeminal nerve
rather than the intracranial part.
The Meckel’s cavity can be involved either by
extrinsic or intrinsic disease. Extrinsic lesions,
usually bony metastasis, chordoma, or
chondrosarcoma, destroy adjacent bone as they
extend toward the Meckel’s cavity. Intrinsic lesions
simply expand the Meckel’s cavity.
72

73. Pituitary fossa and cavernous sinus lesions may
extend to the Meckel’s cavity or involve the
cavernous portion of the trigeminal nerve divisions
as well.
The trigeminal nerve has three sensory and one
motor nuclei. The sensory nuclei are the principal,
mesencephalic, and spinal sensory.
The cervical extension of the spinal sensory nucleus
explains the relation of upper cervical disk
herniation and its association with trigeminal
sensory neuropathy.
73

74. Multiple sclerosis, glioma, and infarction are the
most common brainstem and upper cervical cord
lesions resulting in fifth cranial nerve symptom.
Less common lesions include metastasis, cavernous
hemangiomas, hemorrhage, and arteriovenous
malformation.
Rarely, rhombencephalitis may develop as a result
of retrograde extension of herpes simplex virus
type 1 from the trigeminal ganglion into the
brainstem.
74

75. Consists of flushing and
sweating of the ipsilateral
face in the distribution of
the auriculotemporal nerve
upon eating or tasting.
It is occasionally seen
following injury or infection
of the parotid gland area .
75

76. It is also known as the Reader
Syndrome and is a rare
disorder produced by tumors
arising in the semilunar
ganglion.
Characterised by trigeminal
neuralgia at the onest ,
followed by facial anesthesias
on the affected side.
The muscles of mastication
are found weakened or
paralysed.
76

77. In conclusion, a variety of conditions may involve
the different segments of the trigeminal nerve.
Knowledge of its anatomic course and its
application allows an understanding of disorders
involving the brainstem, the nerve parts and
adjacent skull base.
77

78. Monhem’s Local Anaesthesia
and Pain Controll in Dental
Practice; C.Richard Bennett,
7th Edition; CBS publication
Cranial Nerves Functional
Anatomy, Stanley
Monkhouse;2nd edition 2006;
Cambridge university press.
Sicher and DuBRULS ORAL
ANATOMY by E. LLOYOD
DuBRUL, 8th
Edition,Ishiyaku
EuroAmerica, Inc. Publishers
Gray’s anatomy, Henry Gray;
40th edition
78

79. 79