Trigeminal Nerve

TRIGEMINAL NERVE
❑Vt cranial nerve
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❑ It is the largest cranial nerve and contains both sensory and motor fibers
❑ Receives 3 large sensory nerves
▪ upper(ophthalmic n.)
▪ middle (maxillary n.)
▪ lower (mandibular n.) (+motor)
 NUCLEI OF TRIGEMINAL NERVE
❑ It has four nuclei:
1. Main sensory nucleus
2. Spinal nucleus
3. Mesencephalic nucleus
4. Motor nucleus
 NUCLEI OF TRIGEMINAL NERVE
❑ Main sensory nucleus
▪lies in posterior part of pons lateral
to the motor nucleus
❑ Spinal nucleus
▪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
❑ Mesencephalic Nucleus
▪composed of unipolar cells situated
in lateral part of gray matter around
cerebral aqueduct and it extends
inferiorly into pons as far as the
main sensory nucleus
❑ Motor nucleus
▪is situated in pons medial to main
sensory nucleus
 COURSE OF TRIGEMINAL NERVE
❑Trigeminal nerve leaves
anterior aspect of pons as a
small motor root and a large
sensory root

❑Each root is ensheathed in

pia-arachnoid

❑It passes forward out of

posterior cranial fossa and rests
on apex of petrous bone in
middle cranial fossa here
sensory root expands to form
trigeminal ganglion

❑Ophthalmic, maxillary, and

mandibular nerves arise from
the anterior border of ganglion
 COURSE OF TRIGEMINAL NERVE
❑Ophthalmic nerve (V1)
contains only sensory fibers
leaves skull through superior
orbital fissure to orbital cavity

❑Maxillary nerve (V2) also

contains only sensory fibers
leaves the skull through
foramen rotundum

❑Mandibular nerve (V3)

contains both sensory and
motor fibers and leaves skull
through foramen ovale

❑The sensory fibers to skin of

face from each division supply a
distinct zone with little or no
overlap of dermatomes
 TRIGEMINAL GANGLION
❑ Sensory ganglion

❑ Made up of pseudounipolar nerve cells, with a “T-shape” arrangement of

processes arising from the cell bodies, which divide to form the central and
peripheral processes

❑ Lies in the trigeminal impression on the anterior surface of the petrous temporal
bone near the apex

❑ It occupies a special space of dura called the Meckel or Trigeminal cave

❑Relations:
▪Medially – ICA and posterior part of
cavernous sinus
▪Laterally – Middle meningeal artery
▪Superiorly – Parahippocampal gyrus
▪Inferiorly – Motor root of Vth CN;
greater petrosal nerve; apex of
petrous bone; foramen lacerum
 SENSORY COMPONENT OF TRIGEMINAL NERVE
❑Branches of the unipolar cells of the trigeminal ganglion are divided into central
and peripheral branches
❑The peripheral processes of these
cells are sensory
❑The central processes of these cells
form sensory root of trigeminal nerve
❑ About half the fibers divide into
ascending and descending branches
when they enter the pons
❑Ascending branches terminate in
main sensory nucleus
❑Descending branches terminate in
spinal nucleus
❑ Touch and pressure nerve fibers
terminate in the main sensory nucleus
❑Pain and temperature pass to spinal
nucleus
SENSORY COMPONENT OF TRIGEMINAL NERVE
❑The remainder ascend or descend in
the brainstem without division
❑Proprioceptive impulses from
muscles of mastication are carried by
fibers of unipolar cells of the
mesencephalic nucleus that have
bypassed trigeminal ganglion
❑ Axons in the main sensory nuclei,
spinal nuclei and central processes of
cells in mesencephalic nucleus crosses
the median plane and ascend as
trigeminal lemniscus to terminate on
nerve cells of ventral postero-medial
nucleus of the thalamus.

❑Axons travel through genu internal

capsule to postcentral gyrus ❑
 MOTOR COMPONENT OF TRIGEMINAL NERVE
❑Motor nucleus lies in grey
matter beneath rhomboid
fossa

❑Situated in pons close to

medial side of main sensory
nucleus of V

❑Cells of motor nucleus give

rise to axons that form motor
root

❑Motor nucleus supplies

muscles of mastication, tensor
tympani, tensor veli palatini,
mylohyoid and anterior belly
of digastric muscle.
 OPHTHALMIC NERVE (Va)
❑ Smallest of 3 peripheral branches of trigeminal ganglion
❑ Sensory nerve
❑ The cutaneous branches supplies structures derived from frontonasal
prominence i.e.
1. Eyeball
2. Lacrimal gland
3. Conjunctiva
4. Nasal & paranasal mucosa
5. Skin of scalp, forehead, eyelids and nos e
 COURSE OF OPHTHALMIC NERVE (Va)
❑ Passes forwards from trigeminal cave

❑ Through the lateral wall of cavernous sinus:

▪ above maxillary n.
▪ below trochlear n.

❑ Divides into three branches (Frontal; Lacrimal and Nasociliary nerves) prior to
entry into superior orbital fissure to enter into the orbit
 BRANCHES OF OPHTHALMIC NERVE (Va)
Frontal nerve
❑ Largest of 3 terminal branches of Va
❑ Passes forwards in orbit just under its roof and ½ way through it divides into:

1. Supratrochlear nerve
▪ Smallest terminal branch
▪ It runs anteromediallly in the roof of the orbit, passing above trochlear nerve
and emerges through the frontal notch
▪ Supplies: conjunctiva; skin of upper eyelid and skin of midline of forehead
above root of nose
1. Supraorbital nerve
▪Larger terminal branch
▪It transverse through the supra-
orbital foramen
▪ Supplies: scalp up to vertex, rest of
forehead, central upper eyelid;
conjunctiva and frontal sinus
 BRANCHES OF OPHTHALMIC NERVE (Va)
Lacrimal nerve
❑ Smallest of 3 terminal branches of Va
❑ Enter the orbit through the lateral part of SOF
❑ It receives communication from the zygomatico-temporal nerve and passes deep to
the lacrimal gland
❑ Supplies
▪ Conjuctiva and upper eyelid laterally
▪ Parasympathetic and sensory to lacrimal gland

Secretomotor fibres to the gland

from the greater petrosal nerve
via the zygomatico-temporal
nerve
 BRANCHES OF OPHTHALMIC NERVE (Va)
Nasocillary nerve
❑ Terminal branches of Va
❑ Begins in the lateral wall of the anterior part of the cavernous sinus
❑ Enters the orbit through SOF between the two division of the occulomotor nerve
❑ Crosses over to the medial wall of the orbit and ends at the anterior ethmoidal
foramen by dividing into the infratrochlear and anterior ethmoidal nerves
 OPHTHALMIC NERVE (Va)
Branches of the Nasociliary nerve
Branches of nasociliary nerve Innervation
Communicating branch to ciliary Sensory root to the ganglion
ganglion
Two-three long ciliary nerves Cornea, iris and ciliary body
Posterior ethmoidal nerve Ethmoidal and sphenoidal air sinuses
Infratrochlear nerve Conjunctiva, lacrimal sac and caruncle, medial ends of
(smaller terminal br.) the eye lids and upper half of the external nose
Anterior ethmoidal nerve Gives off two internal nasal branches, i.e. Medial and
(larger terminal br.) lateral to supply the mucosa of the nose
It emerges at the lower border of the nose as the
external nasal nerve to supply the skin of the lower half
of the nose
OPHTHALMIC NERVE (Va)
 MAXILLARY NERVE (Vb)
❑ A peripheral branches of trigeminal ganglion
❑ Sensory nerve
 COURSE OF MAXILLARY NERVE (Va)
❑ Passes through the lateral
wall of the cavernous sinus
below Va.
❑ Leaves MCF by traversing
foramen rotundum
❑Maxillary nerve enters the
pterygopalatine fossa (PPF)
❑Exiting PPF, it continues as
infraorbital nerve and enters
the orbit through the
infraorbital fissure
❑It runs on the floor of the
orbit, firstly in a shallow groove
and then in the infraorbital
canal
❑ Finally emerges through the
infraorbital foramen
CUTANEOUS BRANCHES OF MAXILLARY NERVE
❑ Three cutaneous branches:
▪ Zygomaticotemporal nerve
▪ Zygomaticofacial nerve
▪ Infraorbital nerve

❑ The cutaneous branches supplies structures derived from frontonasal

prominence i.e.
1. Skin of the lower eye lids
2. Prominence of the cheeks
3. Alar part of the nose
4. Part of the temple
5. Upper lip
 CUTANEOUS BRANCHES OF MAXILLARY NERVE
Zygomatico-facial nerve
❑ Transverse through the inferolateral angle of the orbit, and emerges on the face
through a foramen on the zygomatic bone
❑ Supplies the skin on the prominence of the cheeks
❑ Forms a plexus with the zygomatic branch of the facial nerve and the palpebral
branch of the maxillary nerve
 CUTANEOUS BRANCHES OF MAXILLARY NERVE
Zygomatico-temporal nerve
❑Entersthe orbit through the lateral
end of the inferior orbital fissure and
runs on the lateral wall to enter the
zygomatic bone
❑ Then transverse with the zygomatic
canal to enter anterior part of the
temporal fossa
❑ Supplies the skin on the temples
❑ It communicates with the facial and
auriculotemporal nerves
❑Gives off a communicating branch
carrying parasympathetic postganglionic
fibres from pterygopalatine ganglion to
the lacrimal gland
 CUTANEOUS BRANCHES OF MAXILLARY NERVE
Infraorbital nerve
❑ Emerges onto the face through the infraorbital foramen
❑ Gives off the following 5 branches:

Branches of Infraorbital nerve Innervation

Middle superior alveolar nerve Upper premolar teeth
Anterior superior alveolar nerve Upper incisors and canine teeth; maxillary sinus;
antero-inferior aspect of nasal cavity
Palpebral nerve Skin over the lower eyelid
(terminal branch)
Nasal nerve Skin on the side of the nose and movable part of the
(terminal branch) nasal septum
Superior labial nerve Skin over the anterior parts of the cheeks and upper
(terminal branch) eyelids

Clinical Significance: Infraorbital nerve is commonly implicated in trigeminal

neuralgia, which is amenable to cryotherapy where medical therapy fails
 PTERYGOPALATINE GANGLION (PPG)
❑Largest parasympathetic peripheral
ganglion in the head region
❑ It serves as a relay station for
preganglionic, secretomotor fibres to glands
❑ Its postganglionic fibres join all
‘ganglionic’ branches of Vb
❑It is ultimately secretomotor to the
lacrimal gland & mucus glands of paranasal
sinuses, nose, palate and pharynx.
❑ It lies in the PPF below Vb
❑Pterygopalatine ganglion is related to the
maxillary nerve, but functionally connected
to the facial nerve via its greater petrosal
branch
❑Sensory root – comes from Vb and merely
traverse the ganglion
 BRANCHES OF MAXILLARY NERVE via PPG
Orbital branches:
❑ Passes through the inferior orbital fissure
❑ Supplies the periosteum of the orbit and orbitalis muscle

Palatine branches:
❑ Greater palatine nerve
▪ Traverses through the greater
palatine canal
▪ Supplies: Postero-inferior quadrant
of lateral nasal wall and adjacent
floor of nose; hard plate and
maxillary sinus
❑ Lesser palatine nerves
▪Traverse through the palatine
foramina
▪ Supplies: soft palate and tonsil
 BRANCHES OF MAXILLARY NERVE via PPG
Nasal branches:
❑ Enter the nasal cavity through the sphenopalatine foramen
❑ Lateral posterior superior nasal nerves:
▪ Supplies: Posterior parts of the superior and middle conchae
❑ Medial posterior superior nasal nerves
▪ Supplies: Posterior aspect of the roof of the nose and nasal septum
❑ Nasopalatine nerve
▪ Supplies: Gum behind the incisors

Pharyngeal branch:
▪ Traverses through the palatinovaginal canal
▪ Supplies: Part of the nasopharynx behind the auditory tube

Lacrimal branch:
▪ Supplies: Secretomotor fibres to lacrimal gland
 MANDIBULAR NERVE (Vc)
❑ The largest peripheral branches of trigeminal ganglion
❑ Mixed nerve (sensory + motor)
❑ Supplies all structures derived from the mandibular or first branchial arch
 COURSE OF MANDIBULAR NERVE (Vc)
❑ Begins in the MCF through a
large sensory root and a
small motor root
❑ Sensory root arises from the
lateral part of the trigeminal
ganglion and leaves the
cranial cavity via foramen
ovale
❑ Motor root lies deep to the
trigeminal ganglion and
sensory root
❑ It also passes through
foramen ovale to join the
sensory root thus forming the
main trunk
❑ The main trunk lies in the
infratemporal fossa and
divides into a small anterior
trunk and a large posterior
trunk
 BRANCHES OF MANDIBULAR NERVE
❑ Main trunk branches:
▪ Meningeal branch
✓ Enters the skull through foramen spinosum with the MMA
✓ Supplies: dura mater in MCF
▪ Nerve to medial pterygoid
✓ Arise close to the optic ganglion
✓ Supplies: medial pterygoid muscle (deep surface); tensor veli palatini;
tensor tympani muscles
 BRANCHES OF MANDIBULAR NERVE
❑ Anterior trunk branches:
▪ Buccal nerve
✓Only sensory branch of anterior division of Vc
✓Passes between the two head of lateral pterygoid
✓Supplies: skin and mucous membrane related to buccinator muscle + labial
aspect of gums of molar and premolar teeth

▪ Masseteric nerve
✓Upper border of lateral pterygoid
muscle just in front of TMJ
✓Passes laterally through the
mandibular notch to the deep
surface of the masseter muscle
✓ Supplies: masseter muscle +TMJ
 BRANCHES OF MANDIBULAR NERVE
❑ Anterior trunk branches:
▪ Deep temporal nerves
✓ Two nerves: anterior & posterior
✓ Passes between the skull and lateral pterygoid and enters the deep surface
of temporalis

▪ Nerve to lateral pterygoid

✓ Enters the deep surface of the muscle
 BRANCHES OF MANDIBULAR NERVE
❑ Posterior trunk branches:
▪ Auriculotemporal nerve
✓Emerges onto the face behind the TMJ within the superior surface of the
parotid gland
✓Ascends posterior to the superficial temporal vessels, passing over the
posterior root of zygoma and divides into superficial branches:
➢Auricular part supplies: skin over tragus; upper part of pinna; ECM;
tympanic membrance
➢ Temporal part supplies: skin over temple
➢ Auriculotemporal nerve supplies: parotid gland (secretomotor) + TMJ
 BRANCHES OF MANDIBULAR NERVE
❑ Posterior trunk branches:
▪ Lingual nerve
✓ One of the two terminal branches of the posterior division of Vc
✓ lies between the mandibular ramus and the muscles in
the pterygomandibular space
✓Supplies: Sensory anterior two-thirds of the tongue and floor of the mouth
✓ Fibres from chorda tympani is secretomotor to submandibular and
sublingial glands
 BRANCHES OF MANDIBULAR NERVE
❑ Posterior trunk branches:
▪ Inferior alveolar nerve (IAN)
✓ Largest terminal branches of the posterior division of Vc
✓ runs lateral to medial pterygoid and sphenomandibular ligament
✓ Enters mandibular foramen and runs in the mandibular canal
✓ Branches:
➢Mylohyoid branch (motor):
supplies mylohyoid muscle +
anterior belly of digastric
➢ IAN: supplies lower teeth
and gums
➢Mental nerve: supplies skin
of the chin + skin and mucous
membrane of the lower lip
➢Incisive branch: labial aspect
of gums of canines and incisor
teeth
 CLINICAL SIGNIFICANCE
Trigeminal neuralgia
▪ is a chronic pain condition that affects the trigeminal nerve, which carries
sensation from your face to your brain
▪ trigeminal neuralgia causes even mild stimulation of your face, such as from
brushing your teeth or putting on makeup to trigger a jolt of excruciating pain
▪ affects women more often than men, and it's more likely to occur in people
who are older than 50
▪ Treatment includes: surgery, injections or medication