Trigeminal Nerve

Trigeminal nerve is the largest cranial nerve. Its cranial nerve number V
(its the largest cranial nerve). It originates from the lateral aspect of the
pons in the brain with two roots: a large sensory root "its an afferent mean
!"#$ also compose% of the process of neuron" an% a small motor root "its
an efferent".
&where %oes those neuron locate%'
( in the trigeminal ganglion.
&what is the smallest cranial nerve'
(its the trochlear the most slen%er one.
The large sensory root is compose% of processes of neuron cells of the
trigeminal ganglion.
The small motor root usually %escen%s out through foramen ovale as part
of the man%ibular nerve ()
r%
branch of the trigeminal). *otor function is
only carrie% by the man%ibular branch of the trigeminal nerve.
&+hat is a ganglion'
, ganglion is the aggregation of nerve cell bo%ies that synapse with each
other in the peripheral nervous system .
&+hat is the trigeminal ganglion'
Trigeminal ganglion is sensory so it is ma%e up of synaptic sensory a-ons.
after the synapse the sensory neurons clear into a sensory root into the
brain.
/ocation: in the mi%%le cranial fossa near ape- of the petrous part of
temporal bone
Trigeminal ganglion is 01/2 sensory synapses an% it only happens
01/2 to sensory neurons.
3hape: It is crescent (curve%) in shape4 that is why sometimes it is calle%
semi(lunar ganglion. It has a concave posterior part an% conve- anterior
bor%er4 the conve- anterior bor%er usually pro%uces the sensory a-ons
forming: V5 60phthalmic7. V8 6*a-illary7. V) 6*an%ibular7.
+hile the motor root passes medially and deep to the trigeminal ganglion
(without entering the ganglion) through foramen ovale to become part of
the man%ibular nerve.
*Divisions of the Trigeminal Nerve:
0phthalmic (V5): totally sensory nerve4 usually goes to the orbit
through the superior orbital fissure
*a-illary (V8): also totally sensory an% passes through foramen
rotun%um to the pterygo(palatine fossa enter with inferior orbital fusser to
floor of the orbit then infraorbital groov of the ma-illa to infraorbital canal
"we calle% it that because pass within the ma-illa".
*an%ibular (V)): carries both sensory an% motor innervations. passing
%own through foramen ovale to the infratemporal notch where it %ivi%e to
its all terminal branch "its very important to us as %entist".
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3tarting with the ophthalmic nerve (V1):
:ntirely sensory branch. sensory to the structures within the orbit (general
sensation to the orbit4 while special sensation to the orbit comes from the
optic nerve 6;.1 87) an% anterior half of the scalp (through supra(orbital
an% supra(trochlear branches). It is also sensory to the upper eyeli%
(through infra(trochlear an% lacrimal nerve). ,n% it also supplies the
anterior part of the nasal cavity %own to the tip of the nose (through the
anterior ethmoi%al nerve which gives internal an% e-ternal nasal).
It %ivi%es within the mi%%le cranial fossa <ust before it gets into the
superior orbital fissure into three main branches. those three branches will
enter the orbit through the superior orbital fissure. The branches are:
1. The frontal branch "the largest one" it %ivi%e to supra orbital =
supra trochlear nerve" its gives sensation to forehea% area. goes
superiorly towar%s the frontal bone .
2.The lacrimal nerve goes laterally to the lacrimal glan% "its the
smallest one = %oes not go to the lacrimal glan% its go to the lateral
aspect of upper eyeli%" its sensory" it not relate% to the special
sensation".
3.The nasociliary : "interme%iate in si>e = consi%ere% the 5
st
branch
from the ophthalmic nerve " it gives five branches two the nose anterior
= posterior ethmoi%al two goes to eyeball short or commutating = long
at last the terminal branch goes to the infra trochlear nerve" turns from
the lateral to the me%ial aspect (6naso7 referring to the nasal cavity.
6ciliary7 referring to the eyeball). It gives cilliary branches or nerves to
the eyeball an% nasal branches which are the ethmoi%al branch.
Frontal nerve:
+hen we loo? at the frontal nerve we ?now it enters the orbit through the
upper part of the superior orbital fissure. an% then it passes forwar% on the
superior aspect of the levator palperea s!perioris muscle "that levator
!pper eyeli"". then it %ivi%es into two branches: the supra(trochlear which
is the smaller one4 an% the supra(orbital which is the larger one.
*Frontal 1erve @ranches "both of them gives sensation to the forehea%":
3upra(trochlear: passes above the trochlea or superior to the superior
obliAue. to the me%ial part of the trochlea "its a loop BCDE a fibrous tissue
contain insi%e it the superior obliAue ten%on .
3upraorbital: passes through supra(orbital foramen or notch to supply the
forehea% an% anterior half of the scalp. it also sen%s a branch to the (I
coul%nt hear the wor%) membrane covering the frontal air sinus.
#acrimal:
, slen%er nerve that enters the orbit through the upper part of the superior
orbital fissure. once it is in the orbit it passes on the upper bor%er of the
lateral rect!s muscle an% it goes into the lacrimal glan% but %ont supply
it "it a sensory nerve ". it goes out to supply the s?in of lateral part of the
upper eyeli%. the autonomic parasympathetic supply to the lacrimal glan%
came from the facial nerve then to the pterygo(palatine ganglion .as it
passes its terminal part <oins other nerve fibers. those fibers are
parasympathetic secreto(motor nerve fibers to the lacrimal glan% which
stimulate the pro%uction of the Tears.= usually when it pass from the
ma-illary nerve to the lacrimal nerve to supply the lacrimal glan%. (post(
ganglionic parasympathetic fibers).
&1ote: Freater petrosal is the pregangilionic nerve for this ganglion
It go out from petrus part of temporal bone = goes within the
pterygo(palatine fossa then %o a synapse in the pterygo(palatine
ganglion then the post(synaptic fibers it goes out with oraclo(tempral
go out from the ma-illary >ygomatico(facial branch then to the
lacrimal for the ophthalmic $hy cause its wea? nerve continue with
it until they arrive to the lacrimal glan% .
Nasocilliary:
It enters the orbit through the lower part of the superior orbital fissure.
when it first enters it is on the lateral si%e. then it goes from the lateral to
the me%ial aspect along $ith the ophthalmic artery over the optic nerve.
,fter that it passes forwar% above the upper bor%er of me"ial rect!s
muscle an% terminates in what we call the infra(trochlear nerve.
It usually gives out F%V& ranches (you have to ?now these branches):
1. ;iliary ganglion : it is a communicating branch to the ciliary ganglion
within the orbit. The synapse between the parasympathetic fibers
which go to the sphinictor pupili muscles happen here. The
communicating branch <ust hol%s up the ganglion (it %oesnt have to
%o anything with it). it is only a sensory nerve to the eyeball (general
sensation).
2. /ong ciliary nerves : they enter the orbit an% usually pass between the
choroi% an% the sclera all the way anteriorly to reach the %ilator
pupilli muscles. those are actually sympathetic fibers. this is what
happens when you go into a %ar? room.
3. Gosterior ethmoi%al nerve : passes through the posterior ethmoi%al
foramen in the orbit. to get into the sphenoi%al air sinus an% the
ethmoi%al air cells. mainly the posterior ethmoi%al air cells. so it
provi%es sensory innervation to the sphenoi%al sinus an% ethmoi%al
air cells "%ont arrives to the nasal cavity".(the artery arrives the
nasal cavity but nerve %ont ) (important).
4. ,nterior ethmoi%al : gets through the anterior ethmoi%al foramen.
after it passes there it goes to the anterior cranial fossa. then it goes
bac? to the roof of the nasal cavity anteriorly where it provi%es
sensation to the anterior part of the nasal cavity4 by becoming the
internal an% e-ternal nasal nerves. the e-ternal nasal goes outsi%e "on
bri%ge of the nose" to the face specifically to the e-ternal nose.
3o the anterior ethmoi%al nerve passes through the anterior
ethmoi%al foramen. enters the anterior cranial fossa. then goes
through a small fle- between the cribriform plate an% the crista galea
where there is a small opening through which it enters to get to the
nasal cavity. provi%ing the anterior nasal cavity an% terminating as
the e-ternal nasal nerve.
5. Infra(trochlear nerve : "the terminal branch of nasocilliary nerve"
from its name (infra(trochlear) it goes below the poly "BCDE" of the
superior obliAue muscle to supply the s?in on the me%ial part of the
upper eyeli% an% even a%<acent part of the nose.
The Hr. Iepeats the previous notes many times while showing the
movement of the nerves on the sli%es).
This is the story of the ophthalmic nerve.
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'a(illary nerve(V2):
*a-illary nerve is also totally sensory to the s?in over the ma-illary
region. to the upper teeth an% to the palate (Feneral sensory).
It passes through foramen rotun%um to the pterygo(palatine fossa then
through the inferior orbital fusser in to the ma-illa 4 once it is there it starts
to %ivi%e.
&what is the terminal branch for the ma-illary artery '
3pheno(palatine artery.
&*a-illary 1erve @ranches:
i. +hether it is %irect or in%irect branches4 it usually gives three %ental
branches:
1. 3uperior anterior alveolar nerve.
2. 3uperior mi%%le alveolar nerve.
3. 3uperior posterior alveolar nerve.
(we most ?now each one of them what they supply ).
ii. It also gives three facial branches:
1. Infra(orbital nerve "its the terminal branch of ma-illary nerve".
2. Jygomatico(facial nerve.
3. Jygomatico(temporal nerve.
iii. ,n% three branches to the palate:
1. Freater palatine nerve: to the har% palate.
2. /esser palatine nerve: to the soft palate.
3. Incisive or 1aso(palatine nerve: to the anterior teeth.
iv. ,lso. it gives three other main branches:
1. *eningeal branch: into the mi%%le cranial fossa.
2. Gosterior lateral nasal branches: to the lateral wall of the nasal cavity
(posterior half).
3. @ranches to the pterygo(palatine ganglion: two communicating
branches <ust to hol% the ganglion4 they have nothing to %o with the
ganglion.
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3tarting with the first three:
%. )!perior *lveolar Nerves:
1. Gosterior alveolar: it is a %irect branch from the ma-illary nerve.
It goes to provi%e innervations to the posterior teeth. e-cept the
mesial root of the first molar (although sometimes it %oes4 but
more often it %oesnt).
,fter giving that branch4 the ma-illary nerve enters the inferior orbital
fissure to the infra(orbital groove. ,t the level of the inferior orbital fissure
it is calle% the infra(orbital nerve4 it passes on the floor of the orbit. then it
gives out the other superior alveolar nerves (mi%%le an% anterior):
8. *i%%le superior alveolar: usually provi%es sensory sensations to
the premolars an% the mesial root of the first molar.
3. ,nterior superior alveolar: provi%es sensory sensations to the
anterior teeth (canines an% incisors).
%%. The Facial +ranches:
Infra(orbital: the terminal branch of the ma-illary nerve provi%es sensation
to the area or to the s?in of the ma-illa. upper lip an% the labial mucosa
an% labial gingiva. (I.e. from the s?in all the way %eeply to the gingiva).
Jygomatico(facial an% Jygomatico(temporal: both go to a small space on
the lateral aspect of the s?ull. they are both branches of the ma-illary
nerve. Ksually the ma-illary nerve gives one >ygomatic branch which
%ivi%es later on to form Jygomatico(facial an% Jygomatico(temporal. both
of which pass through the >ygomatic foramen on the lateral walls of the
s?ull.
%%%. ,re-palatal ranches:
Foes %own through the pterygo(palatine fossa. through the palatal canal:
5. The anterior one goes to the har% palate an% its calle% 6greater palatine
nerve7.
8. The other one goes to the soft palate an% its calle% 6lesser palatine
nerve7.
). The thir% one goes to the nasal septum. passing the septal wall of the
nasal cavity an% going all the way anteriorly to the incisive canal an% it is
calle% 6incisive nerve7 or 6naso-palatine nerve7.
3o in a Auic? review: The ma(illary nerve (V3)
Foes out of the s?ull through foramen rotun%um into the
pterygopalatine fossa4 there it %ivi%es to form the superior posterior
alveolar nerve.
Then it goes to form the infra(orbital nerve which gives the mi%%le an%
the anterior superior alveolar branches.
,lso the ma-illary nerve gives another branch which is the >ygomatic
nerve. which in turn %ivi%es into Jygomatico(facial an% Jygomatico(
temporal.
In a%%ition to those two. in the face we have the continuation of the
infra(orbital.
3o we have three branches to the face. another three to the teeth. an% the
remaining ones to the palate: greater an% lesser palatine.
'an"i!lar Nerve (V3):
It is a mi-e% nerve. as it contains the small motor root of the trigeminal
nerve. 3o it has two functions: sensory an" motor.
It usually provi%es general sensation to the s?in over the man%ible. to the
anterior an% superior part of the auricle (through auricular branch) an% to
the mental region (through the mental branch). an% to the labial gingiva
near it.
*otor innervations: those will be L muscles:
1- *uscles of mastication (M): *asseter. Temporalis. /ateral
= *e%ial Gterygoi%s "the lateral pterygoi%s is the main opener of the
moth if there is resistance".
2- The tensors (8): Tensor villi palatine an% tensor tympani.
3- *ylohyoi% an% the anterior belly of %igastric.
It goes out of the s?ull through foramen ovale as the main tr!n.. an%
then it goes into the infratemporal fossa. but <ust before it enters the
infratemporal fossa it %ivi%es into: a small anterior %ivision an% a large
posterior %ivision.
The anterior small %ivision has M branches4 ) motor an% 5 sensory
(buccal.nerve).
The posterior large %ivision also has M branches4 5 motor (nerve to
mylohyoi%) an% ) sensory.
(The Hoctor showe% the %ivisions of the main trun? of the man%ibular
nerve on the sli%es).
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The main tr!n. (of the man%ibular nerver) gives two branches:
Nirst is a sensory nerve (the recurrent meningial nerve or as some boo?s
call it nervous spinosus. which is the more common name). it leaves the
main trun? an% goes along with the mi%%le meningeal artery through
foramen spinosum into the meninges (not as written in our te-tboo?:
foramen ovale. most of the time its foramen spinosum) it supplies the
%ura mater over the mi%%le cranial fossa.
The other branch is nerve to me%ial pterygoi%. it provi%es motor
innervation to ) muscles:
1. *e%ial pterygoi% muscle.
2. Tensor villi palatini muscle.
3. Tensor tympani muscle.
Ksually it gives out a communicating branch to hol% the otic ganglion (the
branch has nothing to %o with the ganglion. it only hol%s it in its place.
1ote: The otic ganglion gives synapse to parasympathetic innervation to
the paroti% glan%.
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+ranches of the *nterior Division:
6Glease refer to your boo? about those branches7
1. Two %eep temporal nerves: anterior an% posterior.
2. 1erve to lateral Gterygoi%.
3. *asseteric nerve.
4. @uccal nerve: which is the terminal branch of the anterior %ivision of
the man%ibular nerve (this is the only sensory ranch from the
anterior %ivision) "it give sensation to the chee?. buccal gingiva = to
the s?in over the buccinator muscle".
'asseteric nerve passes latterly above the lateral pterygoi% muscle an%
through the man%ibular notch. to reach the me%ial surface of the masseter
muscle where it gives its motor innervation.
&Ielations: (important)
/ocate% superior to: lateral pterygoi% muscle.
,nterior to: T*O.
Gosterior to: temporalis ten%on (inserte% into the coronoi% process an%
anterior %ivision of the man%ible).
+!ccal nerve passes laterally between the two hea%s of the lateral
pterygoi% muscle to reach the region of the chee?. specifically the region
of the buccinator muscle. It is a sensory nerve4 it gives sensation to: the
s?in an% the infra(man%ibular notch. chee?s an% the buccal gingiva.
It <oins another buccal nerve4 a motor nerve. which is the buccal branch of
the facial nerve which provi%es motor innervation to the buccinator muscle
an% the superior levator muscles.
(The Hr. shows the nerves an% their locations on the sli%es)
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+ranches of the posterior "ivision:
* large "ivision that contains three main nerves:
1. #ing!al nerve: most anteriorly.
2. ,osterior inferior alveolar.
3. a!ric!lo-temporal nerve: most posteriorly.
%nferior alveolar has both motor an% sensory innervations (mi-e%). It is
sometimes referre% to as the /inferior "ental nerve0.
It %escen%s through out the infratemporal fossa in between two structures:
the spheno(man%ibular ligament "prevent the e-cessive lateral movement"
(sphenoi% fossa to the lingual provi%ing protection to this nerve) an% the
ram!s of the man"ile.
Then the nerve enters the man%ibular canal through the man%ibular
foramen. an% e-its at about the level of the secon% premolar where it
%ivi%es into: mental an% incisive branches.
*ental branch leaves through mental foramen giving innervations towar%s
the gingiva an% chee?s.
The inferior alveolar nerve passes through the spheno(man%ibular ligament
an% ramus of the man%ible then it gives a motor branch (nerve to
mylohyoi% muscle) before it enters the man%ibular canal. Then it passes
through the man%ibular canal which is at the level of secon" premolar.
an% then gives the two sensory branches mental an% incisive.
1erve to mylohyoi% %escen%s through the mylohyoi% groove of the
man%ible (you saw it in the lab. its a small linear groove <ust beneath the
mylohyoi%) then superficial to the subman%ibular glan%. then it goes
superiorly to the mylohyoi" an" anterior elly of "igastric m!scle
which it innervates.
The #ing!al nerve %escen%s in front of the inferior alveolar P it is more
anterior( then it goes over the lateral surface of me"ial pterygoi" muscle
= pass lateral to the hayogluosas muscle then me%ial to man%iblar )
r%
molar where it usually <oins the chor%a tympani (from the facial nerve) at
the lower bor%er of the lateral pterygoi%.
,fter that the nerve moves forwar% an% me%ially <ust at the me%ial si%e of
the man%ibular thir% molar. an% this is of high clinical importance because
it can be in<ure% in many cases when e-tracting the thir% molar "its
function is general sensation of ant 8Q) of the tongue .
1ote: the f!nction of the chor"a tympani is special sensation to the
anterior 213s of the tong!e an" parasympathetic innervation to the
s!man"i!lar an" s!ling!al salivary glan"s.
The a!ric!lo-temporal nerve: it has two roots4 from the posterior
%ivision of V). both roots contain an important structure which is the
mi""le meningeal artery. so they embrace this artery. @ehin% the artery
they unite to form the auriculo(temporal nerve which passes bac?war%s
behin% the mi%%le meningeal artery4 %eep into the nec? of the man%ible.
Then it turns upwar%s behin% the T*O along with the superficial temporal
artery "this artery is more ant" an% vein. Ninally it ascen%s bac?war%s.
Its function is giving general sensation to five areas:
1. T'2.
2. Tympanic memrane (o!tsi"e).
3. &(ternal a!"itory meat!s.
4. *nterior 213s of the tong!e.
5. #ateral aspect of the s.!ll.
0ne other important function is carrying the postganglionic
parasympathetic fiers from the lesser petrosal nerve of the
3lossopharyngeal nerve to the paroti" glan" .
+ith that we finish this long epic with the trigeminal nerveR
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Was God's will and strength
THE END
Done +y:
The ,rof
Mazen Mohammad Mosa
Alamri
,.) : %f there is any note $rite !s 4 the faceoo. page to the gro!p
or 4 my page ma5en m alamri .
3oo" l!c..