TRIGEMINAL NERVE

The trigeminal nerve, the largest cranial nerve (Fig 2.1), contains both sensory and motor fibers. General somatic afferent fibers convey both exteroceptive and proprioceptive impulses. xteroceptive impulses of touch,

pain, and thermal senses are transmitted from the s!in of the face and forehead (Fig 2.2)" mucous membranes of the nasal cavities, oral cavities, nasal sinuses, and floor of the mouth" the teeth" the anterior t#o thirds of the tongue" and extensive portions of the cranial dura. $roprioceptive impulses (deep pressure and !inesthesis) are conveyed from the teeth, periodontium, hard palate, and temporomandibular %oint receptor. The nerve is also involved in conveying afferent fibers from stretch receptors in the muscles of mastication. &pecial visceral efferent fibers innervate the muscles, muscles of the eye, and facial muscles. 'fferent fibers constitute the sensory root (portio ma%or), #hereas the efferent fibers form the smaller motor root (portio minor) (Fig 2.(). The trigeminal nerve is attached to the lateral part of the pons by its t#o roots, motor and sensory. The t#o roots enter the middle cranial fossa.
& )&*+, +**T *F T- T+.G /.)'0 ) +1

The fibers of the sensory root of the trigeminal nerve arise from the semilunar (gasserian) ganglion. They enter the brain stem through the side of the pons.

The semilunar ganglion is developed from the neural crest. 0i!e the spinal ganglia it contains unipolar neurons. .t is located in /ec!el2s cavity. The ganglion is crescent shaped. The ganglion, #ith its unipolar neurons, forms central and peripheral processes. The peripheral branches form the ophthalmic, maxillary, and mandibular divisions of the nerve. The central branches are the sensory roots of the trigeminal nerve. These central branches leave the semilunar ganglion and pass bac! and enter the pons, #here they divide into ascending and descending fibers. The ascending fibers terminate in the upper sensory nucleus in the pons lateral to the motor nucleus. The upper nucleus is the sensory (main) nucleus of the trigeminal nerve. These ascending fibers convey light touch, tactile discrimination, sense of position, and passive movement. The upper or main nucleus gives rise to the dorsal trigeminothalamic tract. The sensory fibers of this tac! ascend up#ard. /ost fibers cross to the opposite side and accompany the medial lemniscus to the thalamus. The spinal (bulbospinal) nucleus of the trigeminal nerve gives rise to the ventral trigeminothalamic tract. The spinal nucleus extends caudally from the main sensory nucleus to the second cervical segment. The fibers of the ventral trigeminothalamic tract cross to the opposite side and ascend to the thalamus. They form a loosely arranged bundle in the medial leminscus. From 2

the thalamus these fibers continue on to the cerebral cortex. These fibers convey pain and temperature from the entire trigeminal area. (Table 2.1 for an outline of sensory, motor, and sectretory nerve supply of certain head regions). MOTOR ROOT OF THE TRIGEMINAL NERVE The motor root (Fig. 2.3) of the trigeminal nerve consists of fibers that have their origin in the motor nucleus located in the upper pons. These filaments pass from the pons, along the medial side of the semilunar ganglion. The motor root then passes belo# to the foramen ovale, through #hich it passes to %oint the mandibular division immediately belo# the base of the s!ull. The nerve is chiefly motor, ad its fibers supply the muscles of mastication. .t is often called the masticator nerve. MESENCEPHALIC ROOT OF THE TRIGEMINAL NERVE The mesencephalic root consists of afferent fibers that accompany the fibers of the motor root. ntering the pons from the peripheral distribution of the mandibular division of the trigeminal nerve, these fibers ascend to the mesencephalic nucleus of the trigeminal nerve. This nucleus serves as an afferent station that receives proprioceptive impulses from the

temporomandibular %oint, the periodontal membrane, the maxillary and mandibular teeth, and the hard palate. The mesencephalic nucleus also receives

Table 2.14 *utline of sensory, motor, and secretory nerve supply of certain head regions.
Region 5pper lip 7orner of mouth Sensory ner es &uperior labial fibers of infraorbital nerve of 12 &uperior labial fibers of infraoral nerve of 12 .nferior labial fibers of mental nerve of 1( .nferior labial fibers of mental nerve 0ong buccal nerve of 1( Se!re"ory Mo"or ner es 6uccal branches of 1.. 6uccal and mandibular branches of 1.. /andibular branch of 1.. 6uccal branches of 1..

0o#er lip 7hee! Teeth /axillary

$osterior superior alveolar nerve of 12 to 8, 9, :. /iddle superior alveolar nerve of 12 to 3, ; and mesiobuccal root of 8. 'nterior superior alveolar nerve of 12 to 1,2,(. .nferior alveolar nerve of 1( to 1,2,(,3,;,8,9,:. 0ateral side $osterior superior alveolar nerve of 12 &uperior labial nerve of infraorbital nerve of 12 $alatal side Greater palatine of 12 )asopalatine of 12 0ateral side 0ong buccal nerve of 1( /ental nerve of 1( 0ingual side 0ingual nerve of 1( 'nterior, middle, posterior superior alveolar branches of 12 /ucous glands via sphenopalatine ganglion Greater superficial petrosal nerve of 1..

/andibular Gingivae /axillary

Gingivae /andibular

/ucus membrane of maxillary sainus

Table 2.1# *utline sensory, motor, and secretory nerve supply of certain head regions < cont2d.
Region -ard palate Sensory ner es /a%or portion palatine 12 $remaxillary nasopalatine 12 greater portion Se!re"ory /ucous glands via sphenopalatine ganglion Greater superficial nerve of 1.. &ame as for hard palate $haryngeal branch of sphenopalatine ganglion and by pharyngeal branches .= and = from pharyngeal plexus 6y submandibular ganglion from 1.. via chorda tympani Tensor palatine by 1( all others by cranial part of =. &tylopharyngeal by .= 'll others by cranial part of .= Mo"or ner es

&oft palate

/iddle palatine nerve of 12 and palatine branches of .= $haryngeal branches of 12 and .=

$harynx

Floor of mouth

&ensory branches lingual nerve of 1(

of

afferent impulses from stretch receptors in the muscles of mastication. These fibers are concerned #ith perfect synchroni>ation on controlling the biting force of the %a#s. ?uring mastication, proprioceptors in the muscles, tendons, periodontal membrane, and %oints send impulses through afferent fibers in the rigeminal nerve that enter the brain stem, pass through the mesencephalic nucleus, and synapse (first) in the main nucleus of the trigeminal nerve. &econdary fibers cross the brain stem and ascend to the thalamus. The secondary fibers constitute the dorsal trigeminothalamic fibers of the bulbothalamic tract. They carry impulses of tactile perception from the afferent fibers of the trigeminal nerve. The third synapse occurs as these afferent fibers leave the thalamus and proceed to the postcentral gyrus in the cortex (sensory). These impulses permit a#areness of motion in the %a#s and the position of the mandible and maxilla during che#ing movements. Finally, some of the proprioceptive impulses pass from the main sensory nucleus by means of the secondary trigeminocerebellar fibers to the dentate and emboliform nuclei. The cerebellium, in turn, conveys impulses to the motor cortex.

$IVISIONS OF THE TRIGEMINAL NERVE Three large nerves proceed from the convex border of the semilunar ganglion4 ophthalmic nerve, 11" maxillary nerve, 12" mandibular nerve, 1(. The ophthalmic nerve, or first division of the trigeminal nerve, is a sensory nerve. .t is the smallest of the three divisions, and passes for#ard and enters the orbit through the superior orbital fissure. The maxillary nerve, or second division of the trigeminal nerve, is a sensory nerve. .t begins at the middle of the semilunar ganglion and leaves the s!ull through the foramen rotundum. The mandibular nerve, the largest of the three divisions of the trigeminal nerve, consists of t#o roots4 a large sensory root arising from the semilunar ganglion and a smaller motor root, #hich passes beneath the ganglion to unite #ith the sensory root %ust after it emerges through the foramen ovale. Ophthalmic division The ophthalmic division (Fig 2.;) is the smallest of the three branches of the semilunar ganglion. .t leaves the anterior medial part of the ganglion and passes for#ard in the lateral #all of the cavernous sinus. .ts fibers are sensory, or afferent, from the scalp, the s!in of the forehead, the upper eyelid lining the frontal sinus, the con%uctiva of the eyeball, the lacrimal gland, and

the s!in of the lateral angle of the eye. .t also transmits sensory impulses from the sclera of the eyeball and the lining of the ethmoid cells. .n the middle cranial fossa, the nervus tentorii branches from the ophthalmic division to supply the dura. The ophthalmic division also gives off communication branches to the oculomotor, trochlear, and abducent cranial nerves. 's the ophthalmic division passes for#ard from the cavernous sinus, it divides into three branches4 lacrimal, frontal, and nasociliary nerves. I. La!ri%al ner e The lacrimal nerve is the smallest of the three branches. .t passes into the orbit at the lateral angle of the superior orbital fissure. .t then courses in an anterolateral direction to reach the lacrimal gland. -ere it supplies sensory fibers to the gland and ad%acent con%uctiva. .n the orbit, postganglionic secretory fibers from the sphenopalatine ganglion meet and travel along #ith he lacrimal nerve. These fibers are from the >ygomatic nerve. II. Fron"al ner e The largest of the three branches, the frontal nerve, appears to be a direct continuation of the ophthalmic division. .t enters the orbit by #ay of the superior orbital fissure. 't about the middle of the orbit, the frontal nerve divides into t#o branches4 supraorbital and supratrochlear nerves.

A. Supraorbital nerve The supraorbital nerve is the largest branch of the frontal nerve. .t passes for#ard and leaves the orbit through the supraorbital foramen, or notch, to supply the s!in of the upper eyelid, the forehead, and the anterior scalp region to the vertex of the s!ull. B. Supratrochlear nerve The smallest branch of the frontal nerve is the supratrochlear nerve. .t passes to#ard the upper medial angle of the orbit. -ere it pierces the fascia of the upper eyelid to supply the s!in of the upper eyelid and lo#er medial portion of the forehead. III. Naso!iliary ner e The nasociliary nerve is the third main branch of the ophthalmic division. .t enters the orbit through the superior orbital fissure. 6ranches of the nasociliary nerve are divided into those arising in the orbit, in the nasal cavity, and on the face. A. Branches in the orbit 1. Long Roo" O& T'e Ciliary Ganglion4 The long, or sensory, root arises from the nasociliary nerve. .t contains sensory fibers, #hich pass through the ganglion #ithout synapsing and continue on to the eyeball by means of the short ciliary nerves. @

2. Long Ciliary Ner es4 There are usually t#o or three long ciliary nerves

branching from the nasociliary nerve. They are distributed to the iris and cornea. .n addition, the long ciliary nerves contain postganglionic fibers, from the superior cervical sympathetic ganglion. (. Pos"erior E"'%oi( Ner e4 The posterior ethmoid nerve enters the posterior ethmoid canal to be distributed to the mucous membrane lining the posterior ethmoidal cells and the sphenoid sinus. 3. An"erior E"'%oi( Ner e4 The nasociliary nerve continues anteriorly along the medial #all of the orbit. .n its course, the anterior ethmoid nerve gives off filaments that supply the mucous membrane of the anterior ethmoid cells and frontal sinus. .n the upper part of the nasal cavity, the ethmoid nerve divides into t#o sets of anterior nasal branches, the internal and external nasal branches. a. Internal nasal branches: The internal nasal branches, in turn, divide in the upper anterior part of the nasal cavity into t#o divisions. (1) /edial or &eptal 6ranches4 These branches travel do#n#ard to supply sensory innervation to the mucous membrane of that area.

1A

(2)

0ateral 6ranches4 These branches gives off t#igs to the mucous membrane of the anterior ends of the superior and middle nasal conchae and to the anterior lateral nasal #all.

b.

External nasal branches: 't the end border bet#een the lo#er edge of the nasal bone and the upper edge of the lateral nasal cartilage, the external nasal branch passes externally to supply the s!in over the tip of the nose and the s!in over the ala of the nose.

). Branches arising in the nasal cavity The branches of the nasociliary nerve that arise in the nasal cavity supply the mucous membrane lining the cavity.

11

C. Terminal branches of the ophthalmic division on the face These terminal branches course belo# the trochlear nerve to supply sensory fibers to the s!in of the medial parts of both eyelids, the lacrimal sac, and the lacrimal caruncle. These terminal fibers supply the s!in over the side of the bridge of the nose. IV. A*"ono%i! ganglion asso!ia"e( +i"' "'e o,'"'al%i! (i ision o& "'e "rige%inal ner e. These terminal branches course belo# the trochlear nerve to supply sensory fibers to the s!in of the medial parts of the both eyelids, the lacrimal sac, and the lacrimal caruncle. These terminal fibers supply the s!in over the side of the bridge of the nose. A. Motor or Short (preganglionic, parasympathetic) oot These motor fibers arise from cells in the nucleus of dingerBCestphal. The oculomotor nucleus lies in the gray substance in the mesencephalon. The axons of the autonomic nucleus course #ith the fibers of the oculomotor nerve to the ciliary ganglion. They are the visceral efferent bundle that carries preganglionic fibers to the ciliary ganglion. .n the ganglion, the preganglionic fibers synapse #ith postganglionic fibers #hose neurons form the short ciliary nerves that innervate the sphincter pupillae and ciliary muscles of the iris.

12

). Sensory or long (postganglionic, sympathetic) root The sensory fibers of the ciliary ganglion are derived from the nasociliary nerve of the trigeminal nerve. This root also carries many postganglionic fibers from cell bodies of the superior cervical sympathetic ganglion. They %oin the nasociliary nerve. They pass through the ganglion #ithout synapse to innervate the radial fibers of the dilator pupillae muscle in the iris. C. Sympathetic root 's already mentioned, the sympathetic fibers may come from the sensory root of the nasociliary nerve or direcly from the internal carotid plexus. &hort ciliary nerves emerge from the anterior border of the ciliary ganglion and continue on to the posterior surface of the eyeball. Fibers of the short ciliary nerves contain sensory, parasympathetic, and sympathetic fibers. They run in theinner surface of the sclera to#ard the iris. The postganglionic fibers of the parasympathetic group innervate the circular, or sphincter, muscle fibers of the iris, #hich causes the pupil to constrict. They also innervate the ciliary muscle, #hich changes the convexity of the crystalline lens. $ostganglionic fibers of the sympathetic group pass to the radial fibers of the dilator pupillae muscle in the iris, #hich causes the pupil to dilate. The sensory fibers are afferent from all parts of the eyeball and the con%unctiva.

1(

Ma-illary (i ision The maxillary division of the trigeminal nerve (Fig 2.8) is entirely sensory in function. The maxillary nerve originates at the middle of the semilunar ganglion and continues for#ard in the lo#er part of the cavernous sinus. .t then passes to the foramen rotundum, through #hich it leaves the cranial fossa and enters the pterygopalatine fossa. .t enters the inferior orbital fissure to pass into the orbital cavity. -ere it turns laterally in a groove on the orbital surface of the maxilla, called the infraorbital groove. 7ontinuing for#ard, the second division emerges on the anterior surface of the maxilla through the infraorbital foramen, #here it divides. The maxillary division of the trigeminal nerve transmits sensory (afferent) impulses from the lo#er eyelid, the side of the nose, and the upper lip. .t is sensory to all maxillary teeth and their gingivae, the mucous membrane of most of the nasal cavity, the hard and soft palate regions, part of the tonsillar region, and form the region of the pharynx near the opening of the auditory ( ustachian) tube. .n addition, afferent fibers arising in the mucous membrane lining the maxillary sinus transmit sensory impulses by this division of the fifth cranial nerve. .n its course from the semilunar ganglion, the maxillary division gives off branches in four regions4 in the middle cranial fossa, in the pterygopalatine fossa, in the infraorbital groove and canal, and on the face (terminal branches). 13

I. )ran!'es gi en o&& in "'e %i((le !ranial &ossa .n the middle cranial fossa a small branch, the middle meningeal nerve, passes #ith the middle meningeal artey and its branches to supply the dura #ith sensory fibers II. )ran!'es in "'e ,"erygo,ala"ine &ossa A. !ygomatic nerve The >ygomatic nerve leaves the second division in the pterygopalatine fossa and passes anteriorly and laterally through the inferior orbital fissure into the orbit. -ere it divides into t#o parts4 >ygomaticofacial nerve and >ygomaticotermporal nerve. 1. Zygomaticofacial Nerve4 The >ygomaticofacial nerve passes for#ard on the lateral orbital foramen. The nerve pierces the orbicularis oculi muscle and supplies sensory fibers on the s!in over the prominence of the >ygomatic bone. 2. Zygomaticotemporal Nerve4 The >ygomaticotemporal nerve leaves the orbit bet#een the great #ing of the sphenoid and the >ygomatic bone to enter the temporal fossa. .t supplies sensory fibers to the s!in over the anterior temporal fossa region. B. "terygopalatine (spehnopalatine) nerves

1;

The pterygopalatine nerves are t#o short nerve trun!s that unite at the pterygopalatine ganglion and are then redistributed into several branches. since a great ma%ority of the fibers in the trun!s are trigeminal somatic afferent fibers, #hich merely pass beside or through the ganglion #ithout synapsing, the branches are listed here as belonging to the maxillary nerve rather than the pterygopalatine ganglion. The pterygopalatine nerves also serve as important functional communications bet#een the ganglion and the maxillary nerve. $ostganglionic secretomotor fibers from the pterygopalatine ganglion pass by means of these nerves bac! along the maxillary nerve to the >ygomatic nerve, through #hich they are routed to the lacrimal nerve and the lacrimal gland. Table 2.24 ?istribution of branches of the spnenopalatine ganglion. Secretory to 0acrimal gland /ucous glands of nasal region via nasopalatine and posterior superior lateral nasal nerves. /ucous glands of hard palate region by nasopalatine and greater palatine nerves. /ucous glands of soft palate region by middle palatine nerve" also branches from pharyngeal plexus of .= and =. /ucous membrane of pharynx by pharyngeal branch" also by .= and =. Sensory from 0acrimal gland, 1." lacrimal nerve )asal mucosa, 12 nasopalatine and posterior superior lateral nasal branches. /ucosa of hard palate by nasopalatine and greater palatine branches of 12. /ucosa of soft palate by middle palatine branch of 12" also branches of pharyngeal plexus by .= and =. /ucous membrane of pharynx by pharyngeal branch" also by .= and =.

18

The branches of distribution of the pterygopalatine nerves are divided into three groups4 orbital, nasal, and palatine. 1. Orbi"al )ran!'es4 T#o or three lines filaments enter the orbit by means of the inferior orbital fissure and supply the periosteum of the orbit and the mucous membrane of part of the posterior ethmoid cells and the sphenoid sinus. 2. Nasal )ran!'es4 .n the nasal cavity, the branches divide into the posterior superior lateral branches and the medial or septal branch. a. Posterior superior lateral nasal branches 4 These branches transmit sensory impulses from the mucous membrane of the nasal septum and posterior ethmoid cells. b. Medial or septal branch4 This branch passes do#n#ard and for#ard. .t transmits sensory impulses from the mucous membrane over the vorner. .t then descends in the incisal canal and ramifies in the mucous membrane of the premaxillary region of the hard palate. (. Pala"ine )ran!'es4 The palatine branches descend in the

pterygopalatine canal, #here the fibers usually divide into three stands4 greater or anterior palatine, middle palatine, and posterior palatine. a. Greater of anterior palatine nerve 4 This nerve emerges on the hard palate by passing through the greater palatine foramen and courses

19

in an anterior direction bet#een the osseous hard palate and the mucoperiosteum to supply the ma%or part of the hard palate and the palatine gingivae. .t brea!s up into numerous branches in its course and finally extends as far for#ard as the premaxillary palatine mucosa, #hich is also supplied by terminal branches of the nasopalatine nerve. b. Middle palatine nerve4 This nerve emerges from the lesser palatine foramen. .ts fibers are sensory to the mucous membrane of the soft palate. c. Posterior palatine fibers4 These nerve fibers, emerging from the lesser palatine foramen, go to the mucous membrane of the tonsiller area as part of the sensory supply to the tonsil itself. #. "osterior superior alveolar braches T#o or three branches leave the maxillary division %ust before it enters the inferior orbital fissure. They pass do#n#ard and continue on the posterior surface of the maxilla. 'n internal branch of the posterior superior alveolar nerve goes along #ith a branch of the internal maxillary artery through the posterior superior alveolar canal, #hich opens on the posterior surface of the maxilla.

1:

.n those bone, the nerve passes do#n the posterior or posterolateral #all of the maxillary sinus, giving off sensory fibers to the mucous membrane of the sinus. .t then supplies the maxillary molars and their gingivae. Cithin the depths of the alveoli, or tooth soc!ets, some nerve filaments pass to supply the periodontal membranes" #hereas others, the pulpal fibers, pass through the apical foramina of the roots of the molar teeth to supply the dental pulps. $. Branches in the infraorbital groove and canal The nerve in the infraorbital groove and canal becomes !no#n as the infraorbital nerve. From this groove serval fibers leave the infraorbital nerve and descend. 1. Mi((le S*,erior Al eolar Ner e# The middle superior alveolar nerve branches #ithin the mucous membrane of the maxillary sinus to %oin #ith other alveolar nerves in forming the superior dental plexus of nerves. .n some cases the middle superior alveolar nerve leaves the infraorbital nerve in the posterior part of the floor of the infraorbital canal and passes in a do#n#ard and anterior direction to#ard the apices of the maxillary bicuspids. .n other cases the middle superior alveolar nerve leaves the main trun! in the floor of the infraorbital canal near the infraorbital foramen and passes do#n#ard in the anterior or anterolateral #all of the sinus. &ome authorities claim that the middle superior alveolar nerve may be missing and that the maxillary bicuspids receive their sensory innervation from the superior dental plexus. 1@

Chether the maxillary bicuspids can be anestheti>ed by the infraorbital in%ection or by the posterior superior alveolar in%ection depends on the point #here the middle superior alveolar nerve leaves the infraorbital nerve. .n some cases infiltration anesthesia about the maxillary bicuspids may be necessary. 2. An"erior S*,erior Al eolar Ner e# The anterior superior alveolar nerve descends from the infraorbital nerve %ust inside the infraorbital foramen in the anterior part of the infraorbital canal. The anterior superior alveolar nerves descend in fine canals in the maxilla to pass to the roots of the maxillary central and lateral incisors and cuspid teeth. They also send connecting fibers to the superior dental plexus of nerves #ithin the maxilla. Fibers of the anterior superior alveolar nerves also supply sensory innervation to the mucous membrane of the anterior part of the maxillary sinus as #ell as the labial gingivae of the incisors and cuspid teeth. %. Terminal branches of the ma&illary division on the face 's the infraorbital nerve is about to emerge from the infraorbital foramen on the front of the maxilla, it divides into three terminal nerve branches4 the inferior palpebral, external or lateral nasal, and superior labial branches.

2A

1.

In&erior Pal,erbral )ran!'es4 5sually t#o or three in number, the branches pass up#ard and supply sensory fibers to the s!in of the lo#er eyelid and its con%unctiva.

2.

E-"ernal or La"eral Nasal )ran!'es4 The external or lateral nasal branches pass to the s!in of the side of the nose.

(.

S*,erior Labial )ran!'es4 5sually three or more in number, the branches are distributed to the s!in and mucous membrane of the upper lip.

III. A*"o%i! ganglion asso!ia"e( +i"' "'e %a-illary (i ision o& "'e "rige%inal ner e A. Sphenopalatine ganglion The sphenopalatine ganglion is associated #ith the great superficial petrosal nerve. .t is a part of the seventh cranial nerve and is a parasympathetic ganglion relaying chiefly secretomotor impulses from the nerve (Fig. 2.9). .t contains cell bodies of afferent taste fibers. The ganglion is stellate and lies deep in the pterygopalatine fossa, suspended from the maxillary division of the trigeminal nerve by t#o roots.

21

Fibers of the great superficial petrosal nerve arise in the central nucleus, #hich is called the superior salivatory nucleus. Form this nucleus, fibers pass laterally and caudally and are %oined by sensory fibers of the facial nerve to form the intermediate nerve. The facial nerve and the intermediate nerve cross the petrous part of the temporal bone and traverse the facial canal. The canal curves, and at its sharp curve, or genu, the intermediate nerve expands and becomes the geniculate ganglion. From this ganglion preganglionic parasympathetic fibers leave as the greater superficial petrosal nerve passes from the hiatus of the facial canal on the anterior slope of the petrous portion to enter the middle cranial fossa. .t then passes anteriorly and medially beneath the semilunar ganglion of the trigeminal nerve and passes through the foramen lacerum. 't the lo#er end of this foramen the greater superficial petrosal nerve is %oined by the deep petrosal nerve. The deep petrosal nerve is superficial petrosal and the deep petrosal nerves are then called the nerve of the pterygoid canal, or vidian nerve. The vidian nerve passes through the pterygoid canal, to enter the pterygopalatine fossa, to enter the sphenopalatine ganglion. This ganglion hangs suspended from the maxillary nerve by t#o roots (pterygopalatine neves). They contain sensory fibers from the maxillary nerve and do not

22

synapse #ithin the ganglion. They continue on their #ay to the mucous membrane of the nasal cavity and palate. The pterygopalatine nerve trun!s are communications for the pterygopalatine ganglion, since they are traversed by postganglionic fibers on their #ayto the maxillary nerve, #hich continue on their #ay to the mucous membrane of the nasal cavity and palate. The pterygopalatine nerve trun!s are communications for the pterygopalatine ganglion, since they are traversed by postganglionic fibers on their #ay to the maxillary nerve, #hich continue to the lacrimal gland and other glands of the nasal cavity and palate. The sensory fibers pass through the ganglion, #hereas the parasympathetic fibers synapse in the ganglion. 1. )ran!'es Fro% T'e S,'eno,ala"ine .P"erygo,ala"ine/ Ganglion a. Orbital branches4 *rbital branches are made up of afferent fibers and convey sensory or afferent impulses from the periosteum of the orbit. *thers supply the mucous membrane of the posterior ethmoid cells and the sphenoid sinus. b. Nasal branches4 These nerves are divided into t#o groups4 posterior superior lateral nerves and nasopalatine (long sphenopalatine) nerve.

2(

(1)

$osterior &uperior 0ateral )erves4 These nerves innervate the mucosa over the posterior parts of the nasal conchae.

(2)

)asopalatine (0ong &phenopalatine) )erve4 The nasopalatine nerve (Fig. 2.:) passes do#n#ard and for#ard bet#een the periosteum and the mucous membrane in the region of the vomer bone and, as it continues do#n#ard and for#ard, reaches the floor of the nasal cavity. .t then descends in the incisal canal to appear in the anterior part of the hard palate and supply the mucous membrane of the premaxilla.

c.

Palatine branches !ig" #"$%4 From the sphenopalatine ganglion the palatine branches descend in the pterygopalatine fossa and the

23

pterygopalatine canal. .n the canal the palatine branches separate into these strands4 greater (anterior) palatine, middle palatine, and posterior palatine. (1) Greater or 'nterior $alatine )erve 4 This nerve emerges from the greater palatine foramen in the region of the lateral margin of the palatine bone and medial to the upper third molar. .t then continues for#ard and splits into numerous branches bet#een the osseous roof of the oral cavity and the mucoperiosteum. .t carries sensory and secretory fibers to the ma%or part of the mucous membrane of the hard palate and palatal gingivae. .ts anterior terminal fibers extend for#ard as far as the premaxillary palatine mucosa. (2) /iddle $alatine )erve4 This nerve emerges from a small foramen in the medial aspect of the pyramidal part of the palatine bone to supply sensory and secretory fibers to the mucosa membrane of the soft palate. (() $osterior $alatine )erve4 This nerve usually emerges from a lesser foramen posterior and slightly lateral to the middle palatine nerve. The fibers of the posterior palatine nerve convey sensory and secretory fibers to the mucous membrane in the tonsillar area.

2;

d.

Pharyngeal branch4 This branch conveys sensory and secretory fibers to the mucous membrane of the nasopharynx about the opening of the auditory tube.

e.

&ecretory fibers to the lacrimal gland4 $reganglionic parasympathetic fibers arising in the lacrimal nucleus pass to the geniculate ganglion and then to the sphenopalatine ganglion. The sympathetic postganglionic fibers from the deep petrosal nerve continue on through the ganglion. From the sphenopalatine ganglion, the parasympathetic and the

sympathetic fibers pass bac! to the maxillary nerve and enter the >ygomatic nerve. They leave the >ygomatic nerve in the orbit, %oin the lacrimal nerve, and then go to the lacrimal gland to control its secretion. Man(ib*lar (i ision The mandibular division of the trigeminal nerve (Fig. 2.1A) is the largest of the three divisions. .t is formed by the union of the large sensory (afferent) bundle of fibers and a small motor (efferent) bundle of fibers. 28

The sensory (afferent) root fibers are peripheral extensions of unipolar cells located in the semilunar ganglion. The motor (efferent) root ribers are derived from motor cells located in the medulla oblongata. These fibers become incorporated #ith the sensory fibers in the mandibular trun!. The large sensory root arises from the semilunar ganglion. .ts fibers are distributed to the dura, s!in, and mucous membrane of the chin, chee!, and lo#er lip" the external ear region" parotid gland" temporomandibular articulation" the scalp over the region of the temporal bone" to the lo#er teeth and their gingivae" and to the anterior t#o thirds of the tongue. The motor root innervates the muscles of mastication. .t supplies the temporal, internal and external pterygoid, masseter, and mylohyoid muscles and the anterior belly to the diastric muscles. &ome of its fibers innervate the tensor veli palatini and the tensor tympari muscles. The motor root is located in the middle cranial fossa. .t %oins the sensory root after the latter leaves the semilunar ganglion. The t#o roots pass side by side in the dura of the middle cranial fossa to the foramen ovale. 0eaving the foramen ovale, the t#o roots unite to form a short single trun!. The branches of the mandibular division may be divided into t#o groups4 branches from the undivided nerve and branches from the divided nerve. I. )ran!'es &ro% "'e *n(i i(e( ner e 29

A. Ner *s s,inos*s The nervus spinosus arises outside the s!ull and then passes into the middle cranial fossa to supply the dura and the mastoid cells. ). Ner e "o in"ernal ,"erygoi( %*s!le. ' branch of the motor root passes to innervate the internal pterygoid muscle. This branch passes #ithout interruption to innervate the tensor veli palatini and the tensor tympani muscles. II. )ran!'es &ro% "'e (i i(e( ner e 6elo# the level of the undivided part of the mandibular division, the trun! separates into t#o parts4 anterior and posterior divisions.

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A. An"erior (i sion The anterior division is smaller then the posterior division. .t receives sensory and motor fibers that supply the muscles of mastication, the s!in and mucous membrane of the chee!, and the buccal gingivae and lo#er molars. .t passes do#n#ard and for#ard, #here it divides4 1. 6ranch to external pterygoid muscle 2. 6ranch to masseter muscle (. 6ranches to temporal muscles a. 'nterior deep temporal nerve b. $osterior deep temporal nerve 3. 6uccal (long buccal) nerve '. "terygoid nerve The pterygoid nerve enters the medial side of the external pterygoid muscle to provide its motor nerve supply. (. Massetter nerve The massetter nerve passes above the external pterygoid to traverse the mandibular notch and enter the deep side of the massetter muscle. ). *erves to the Temporal Muscle

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a. 'nterior deep temporal nerve4 This nerve passes up#ard and crosses the infratemporal crest of the sphenoid bone. .t ends in the deep part of the anterior portion of the temporal muscle. b. Posterior deep temporal nerve4 This nerve passes up#ard to the deep part of the temporal muscle. +. Buccal *erve 5sually the buccal nerve passes do#n#ard, anteriorly and laterally bet#een the t#o heads of the external pterygoid muscle. 't about the level of the occlusal plane of the mandibular second and third molars, it divides several branches that ramify on the buccinator muscle. .t then sends fibers to the mucous membrane of the chee! region. *ther fibers distribute sensory innervation to the s!in of the chee!. These fibers are purely sensory. &till other sensory fibers to the buccal gingivae about the mandibular molars and the mucous membrane of the lo#er part of the buccal vestibule. The buccal nerve occasionally contributes to the nerve supply of the second bicuspid and the first molar of the lo#er %a#. 'lmost the entire mucosa of the chee! is supplied by the buccal nerve. ). Pos"erior (i ision The larger posterior division is mainly sensory but also carries some motor components. This division extends do#n#ard and medially and then

(A

branches into the auriculotemporal, the lingual, and the inferior alveolar nerves.

(1

'. Auriculotemporal *erve The auriculotemporal nerve arises by a medial and a lateral root. These roots embrace the middle meningeal artery and unite behind the artery %ust belo# the foramen spinosum. The united nerve passes posteriorly, deep to the external pterygoid muscle, and then bet#een the sphenomandibular ligament and the nec! of the condyle of the mandible. .t traverses the upper deep part of the parotid gland or its fascia and then crosses the posterior root of the >ygomatic arch. .t passes #ith the superficial temporal artery in its up#ard course and divides into numerous branches, to the tragus of the pinna of the external ear, to the scalp about the ear, and as far up#ard as the vertex of the s!ull. a" (ommunications of the auriculotemporal nerve (1) T#o roots of the nerve4 ach root receives communicating fibers from the otic ganglion. These fibers are postganglionic, parasympathetic secretory fibers that have come from the glossopharyngeal nerve by #ay of the lesser superficial petrosal nerve. They control secretion of the parotid gland. (2) 7ommunicating branches to the facial nerve4 These fibers are purely sensory from the auriculotemporal nerve.

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c.

)ranches of the auriculotemporal nerve 4 The auriculotemporal nerve divides into parotid, articular, auricular, meatal, and terminal branches. (1) $arotid branches4 's the auriculotemporal nerve passes the parotid gland, it gives off sensory, secretory, and vasomotor fibers to the gland. The secretory fibers have passed as postganglionic parasympathetic fibers to the gland. The vasomotor sympathetic postganglionic fibers have accomplished the parasympathetic fibers to the gland. (2) 'rticular branches4 *ne or t#o t#igs of sensory fibers pass from the auriculotemporal nerve and enter the posterior part of the temporomandibular %oint. (() 'uricular branches4 The anterior auricular branches are usually t#o in number. They are sensory fibers supplying the s!in of the helix and tragus. (3) /eatal branches4 T#o small branches usually supply the s!in lining the meatus and the tympanic membrane. (;) Terminal branches4 The ma%or part of the filaments of the auriculotemporal nerve pass to supply the scalp over the temporal region.

((

(. ,ingual *erve The lingual nerve is the smaller of the t#o terminal branches of the posterior division of the mandibular nerve. 't first it passes medially to the external pterygoid muscle and, as it descends, lies bet#een the internal pterygoid muscle and the ramus of the mandible in the pterygomandibular space. .t gives off small branches to the interior alveolar nerve that pass as sensory fibers to part of the tonsil and mucous membrane of the posterior part of the oval cavity. .n the pterygomandibular space the lingual nerve lies parallel to the inferior alveolar nerve but medial and anterior to it. .t then passes deep to reach side of the base of the tongue. 't the side of the tongue it lies belo# the lateral lingual sulcus. .n the lateral lingual sulcus it is separated from the tongue by the alveololingual groove. 's it passes for#ard, it loops do#n#ard and medially beneath the submandibular duct. The lingual nerve contributes many sensory fibers to the mucous membrane of the floor of the mouth and gingiva on the lingual surface of the mandible. .t occasionally supplies sensory fibers to the bicuspids and first molar teeth.

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a. (ommunications of the lingual nerve *ith the chorda tympani branch of the facial nerve4 's the lingual nerve passes medially to the external pterygoid muscle, it is %ointed from behind by the chorda tympani nerve. This nerve conveys secretory fibers from the facial nerve. The parasympathetic secretory fibers control the submandibular and sublingual salivary glands. The secretory fibers of the chorda tympani nerve fibers to the submandibular ganglion, #here they synapse. The secretory nerve fibers to the sublingual gland %oin in a small branch from the submandibular ganglion to re%oin the lingual nerve and pass #ith this nerve to the sublingual gland. ). -nferior alveolar nerve The inferior alveolar nerve is the largest of the branches of the posterior division of the mandibular part of the trigeminal nerve. .t passes do#n#ard on the medial side of the external pteryoid muscle and the medial side of the mandibular ramus. *n the medial side of the ramus in the pterygomandibular space, it enters the mandibular foramen. Cithin the mandible the inferior alveolar nerve descends in the inferior alveolar canal and is distributed throughout the body of the mandible. .n the inferior alveolar canal it gives off branches to the mandibular teeth as apical fibers that enter the apical foramina of the lo#er teeth to supply the dental pulps. &ome of the fibers are distributed to the periodontal membrane of the various lo#er teeth.

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6efore the inferior alveolar nerve enters the mandibular foramen it gives off a branch, the mylohyoid branch, #hich contains sensory and motor fibers. The mylohyoid nerve continues do#n#ard and for#ard in the mylohyoid groove. .t passes for#ard belo# the mylohyoid muscle, to #hich it sends motor fibers, and it supplies motor fibers to the anterior belly of the digastric muscle. There is some claim that a t#ig of sensory fibers of the mylohyoid nerve may enter the mandible in the area of the chin to aid in the sensory nerve supply to the mandibular incisors. III. A*"ono%i! ganglia asso!ia"e( +i"' "'e %an(ib*lar (i ision o& "'e "rige%inal ner e. T#o ganglia are associated #ith the mandibular division (Fig. 2.1A)4 submandibular and otic ganglia. A. Submandibular (Subma&illary) ganglion The submandibular ganglion is a small ovoid body that is suspended from the lingual nerve above the submandibular salivary gland. .t is suspended by t#o nerves from the lingual nerve. These parasympathetic fibers are preganglionic, having their origins in the superior salivatory nucleus in the medulla. They course #ithin the intermediate nerve and in the facial canal and group together to form the chorda tympani nerve. The chorda tympani nerve continues do#n and for#ard to %oin the lingual nerve and passes #ith it to the submandibular ganglion.

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The preganglionic parasympathetic fibers enter the ganglion, and there they synapse. /ost of the postganglionic parasympathetic fibers are short. They supply secretory fibers to the submandibular gland. *ther parasympathetic fibers turn up#ard to re%oin the lingual nerve and pass #ith it to the sublingual gland. The submandibular ganglion also receives postganglionic sympathetic fibers from the plexus on the external maxillary artery. B. Otic ganglion The otic ganglion is a flattened ovoid body located on the medial side of the undivided mandibular division of the trigeminal nerve. .t is belo# the foramen ovale and in front of the middle meningeal artery. .t has t#o main roots4 parasympathetic and sympathetic. 1. Parasympathetic Preganglionic &ecretory% !ibers4 These parasympathetic fibers arise in the inferior salivatory nucleus. This group of cells lies in the floor of the fourth ventricle in the medulla. The efferent fibers pass by #ay to the glossopharyngeal nerve through the %ugular canal. .mmediately belo# the canal, they leave the nerve at its petrosal ganglion in the tympanic nerve (Dacobson2s nerve) to pass into the middle ear region. The lesser superficial petrosal nerve emerges from the tympanic plexus. Then it passes on the upper surface of the petrous part to the foramen ovale. The lesser superficial petrosal nerve is the parasympathetic root of the otic ganglion. .n the otic ganglion the (9

postganglionic fibers %oin the auriculotemporal nerve and #ith it go to the parotid gland. 2. &ympathetic +oot4 The sympathetic root is made up of post ganglionic fibers that have originated in the superior cervical sympathetic ganglion and the plexus on the middle meningeal artery. These sympathetic fibers pass uninterruptedly through the otic ganglion. Cith the postganlionic

parasympathetic fibers, they %oin the auriculotemporal nerve and, #ith its glandular branches, continue to the parotid gland. 'fferent, or sensory, fibers from the parotid gland pass by #ay of the auriculotemporal nerve. S*%%ary o& F*n!"ions o& "'e Trige%inal .Fi&"' Cranial/ Ner e '. *phthalmic division 1. &upratrochlear nerve < &ensory from the medial part of the upper eyelid and the lo#er medial part of the forehead" sensory from the con%uctive of the upper eyelid. 2. &upraorbital nerve < &ensory from the s!in of the upper eyelid and the s!in of the forehead and scalp as far bac! as the vertex of the s!ull" sensory from the lining of the frontal sinus.

(:

(.

0acrimal nerve < &ensory from the s!in of the upper eyelid and lateral part of the eyebro# region" sensory from the con%unctiva of the lateral part of the upper eyelid.

3. a.

)asociliary nerve 0ong ciliary branch < &ensory from the eyeball and ciliary ganglion. b. .nfratrochlear nerve < &ensory from the upper and lo#er eyelids and from the side of the nose" sensory from the con%unctiva and the lacrimal sac. c. thmoid branches (1) 'nterior ethmoid branch < &ensory from the lining of the frontal sinus and of the anterior ethmoid cells. (2) $osterior ethmoid branches < &ensory from the lining of the posterior ethmoid cells and the sphenoid sinus. d. .nternal branches < &ensory from the anterior portion of the septum and lateral #alls of the nasal cavity. e. nose. xternal nasal branch < &ensory from the tip of the

6. /axillary division < /iddle meningeal branch

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1.

.n the cranial cavity the maxillary division sends a sensory branch to the dura.

2.

.n the pterygopalatine fossa he maxillary division gives off t#o branches. a. Eygomatic nerve and branches. (1) Eygomaticofacial branch < &ensory from the s!in over the >ygomatic bone. (2) Eygomaticotemporal branch < &ensory from the s!in of the side of the forehead and of the anterior part of the temporal region. b. &phenopalatine nerves (pterygopalatine). (1) *rbital branches < &ensory from the periosteum of the orbit and from the lining of the sphenoid sinus and posterior ethmoid cells. (2) Greater palatine branch (anterior palatine) < &ensory from the mucous membrane of the ma%or part of the hard palate and ad%acent part of the soft palate. (() 0esser palatine branches < &ensory from the mucous membrane of the soft palate and tonsil area. (3) $osterior lateral nasal branches < &ensory over the nasal conchae. 3A

(;) )asopalatine branches < &ensory from the mucous membrane of the lo#er and posterior part of the nasal septum and from the premaxillary part of the hard palate. (8) $haryngeal branch < &ensory from the mucous membrane of the nasopharynx and the area behind the auditory tube. c. $osterior superior alveolar nerve. (1) Gingival branchesB &ensory from the buccal gingiva of the upper molar region and from the mucous membrane of part of the chee!. (2) 'lveolar branches < &ensory from the maxillary molars, except the mesiobuccal root of the upper first molar and their gingivae, and from the mucous membrane of the maxillary sinus. (() .n the infraorbital canal region. a) /iddle superior alveolar nerve < &ensory from the maxillary bicuspids and the mesiobuccal root of the first molar" sensory from the lining of the maxillary sinsu. b) 'nterior superior alveolar nerve < &ensory from the maxillary incisors and cuspid and from the lining of the maxillary sinus. (3) Terminal branches on the face (infraorbital branches). 31

a) .nferior palpebral branches < &ensory from the s!in of the lo#er eyelid. b) 0ateral nasal branches < &ensory from the s!in of the side of the nose. c) &uperior labial branches < &ensory from the s!in of the upper lip. 7. /andibular division 1. )ervus tentorii < &ensory from the dura of the posterior cranial fossa and from the lining of the mastoid cells. 2. 6uccal (long buccal) nerve < &ensory from the mucous membrane and the s!in of the chee! region" sensory from buccal gingavae of the mandibular molar region. (. a. 'uriculotemporal nerve. &ensory from the s!in over the areas supplied by the branches of the facial (1..) nerve, that is, >ygomatic, buccal, and mandibular areas. b. the parotid branch. c. articulation. 32 &ensory from the temporomandibular &ensory from the perotid gland by means of

d.

&ensory from the s!in lining the external auditory meatus and from the lateral surface of the tympanic membrane.

e.

&ensory from the s!in and scalp over the upper part of the external ear and the side of the head up to the vertex of the s!ull.

3.

0ingual nerve < &ensory from the mucous membrane covering the anterior t#o thirds of the tongue" sensory from the mucous membrane of the floor of the mouth and of the lingual side of the mandibular gingivae" sensory from the submandibular and sublingual glands and their ducts. The lingual nerve conveys special sense of the taste from the anterior

t#o thirds of the tongue. .t also contains secretomotor fibers to the submandibular and sublingual salivary glands and the mucous glands in the floor of the mouth. ;. a. .nferior alveolar nerve. ?ental branches < &ensory from all of the lo#er molar and bicuspid (mandibular) teeth and their periodontal membranes.

3(

b.

/ental nerve < &ensory from the s!in of the lo#er lip and chin regions and from the mucous membrane lining of the lo#er lip region.

c.

.ncisive nerve < &ensory from incisors, cuspid teeth, and their periodontal membranes. The trigeminal nerve has a distinct motor root that conveys efferent

fibers to muscles derived from the first branchial arch. The motor fibers %oin #ith fibers of the mandibular and pass as4 1. .nternal pterygoid nerve < .nnervates the internal pterygoid muscle, the tensor veli palatini muscle, and the tensor tympani muscle. 2. (. /asseter nerve < .nnervates the masseter muscle. ?eep temporal branches < $ass as the anterior and posterior deep temporal branches to the temporal muscle. 3. pterygoid muscle. ;. /ylohyoid nerve < .nnervates the mylohyoid and the anterior belly of the digastric muscles. .n passing from the nec! to head the somatic sensory functions of the cervical nerves are ta!en over by the trigeminal nerve. 33 xternal pterygoid nerve < &upplies the external

The central processes of the previously mentioned branches of the nerve send their impulses of pain and temperature bac!#ard and do#n#ard through the lateral part of the pons, forming the spinal tract of the trigeminal nerve. Those impulses subserving tactile sensibilities of the trigeminal nerve pass to the semilunar ganglion and then into the main nucleus of the trigeminal nerve located in the pons.

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