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TRIGEMINAL NERVE

CONTENTS:-
1. Introduction.

2. Classification of cranial nerve.

3. Embryology of trigeminal nerve

4. Nuclei of trigeminal nerve.

5. Trigeminal Ganglion.

6.Course and division of trigeminal nerve.

7. Branches.(ophthalmic, maxillary, mandibular)

8.Ganglia associated with trigeminal nerve.

9. Cranial nerve examination

10.Applied anatomy.

11. Conclusion.

12. References.

INTRODUCTION: The trigeminal, the largest cranial nerve, is the sensory supply to the face,
the major part of the scalp, the teeth, the oral and nasal cavity, and the motor supply to the
masticatory and some other muscle. It also contains proprioceptive nerve fibres from the
masticatory and probably the extra ocular muscle. The trigeminal nerve has three divisions:
ophthalmic, maxillary, and mandibular The nervous system of man is made up of
innumerable neurons which further constitute the nerve fibres.
Nerve: A bundle of fibres that uses chemical and electrical signals to transmit sensory
and motor information from one body part of the body to another.
Neurons: These are specialized cells that constitute the functional units of the nervous
system and have a special property of being able to conduct impulses rapidly from one part of
the body to another.
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CLASSIFICATION OF CRANIAL NERVES

Sensory cranial nerves: contain only afferent (sensory) fibers

ⅠOlfactory nerve

ⅡOptic nerve

Ⅷ Vestibulocochlear nerve

Motor cranial nerves: contain only efferent (motor) fibers

Ⅲ Oculomotor nerve

Ⅳ Trochlear nerve

ⅥAbducent nerve

Ⅺ Accessory nerve

Ⅻ Hypoglossal nerve

Mixed nerves: contain both sensory and motor fibers

ⅤTrigeminal nerve,

Ⅶ Facial nerve,

ⅨGlossopharyngeal nerve

ⅩVagus nerve

DEVELOPMENT:

During the development of embryo, the pharyngeal arches appear in the fourth and fifth
week. It give rise to six pharyngeal arches, of which the 5th arch disappears. Each arch is
characterized by its own:

 muscular component
 nerve component
 arterial component
 skeletal component
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- Trigeminal nerve is derived from 1st pharyngeal arch

Musculature of the first pharyngeal arch includes:-
Muscles of mastication :

Temporalis
Masseter
Pterygoids
Anterior belly of diagtric
Mylohyoid
Tensor tympani
Tensor palatini
The nerve supply to these muscles is provided by mandibular division of trigeminal nerve.
Mesenchyme from the 1st arch also contributes to the dermis of the face, hence sensory
supply to the skin of the face is provided by ophthalmic, maxillary and mandibular branches
of the trigeminal nerve.

TRIGEMINAL NERVE NUCLEI

There are four trigeminal nuclei: one motor and three sensory

The motor nucleus of CNV is in the superior part of the pons, deep to the floor of the 4th
ventricle.

The mesencephalic nucleus of CNV is lateral to the cerebral aqueduct.

The principal sensory nucleus is in the dorsolateral area of the pontine tegmentum at the level
of entry of the sensory fibres.
The spinal nucleus of CNV is in the inferior part of the pons and throughout the medulla

SENSORY COMPONENTS OF TRIGEMINAL NERVE

The sensations of pain, temperature, touch and pressure from the skin of the face and mucous
membrane travel along axons whose cell bodies are situated in the semilunar or trigeminal
sensory ganglion.
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The central process of these cells form the large sensory root of the trigeminal nerve.
About half the fibres divide into ascending and descending branches when they enter the
pons, the remainder ascend or descend without division

The ascending branches terminate in the main sensory nucleus and the descending branches
terminate in the spinal nucleus.
The sensations of touch and pressure are conveyed by nerve fibres that terminate in the main
sensory nucleus. The sensation of pain and temperature pass to the spinal nucleus.
The sensory fibres from the ophthalmic division of the trigeminal nerve terminate in the
inferior part of the spinal nucleus, fibres from the maxillary division terminate in the middle
of the spinal nucleus and fibres from the mandibular division end in the superior part of the
spinal nucleus.

Propioceptive impulses from the muscles of mastication and from the facial and extraoccular
muscles are carried by fibres in the sensory root of the trigeminal nerve.
The axons of the neurons in the main sensory and spinal nuclei now cross the median plane
and ascend as the trigeminal lemniscus to terminate on the nerve cells of the ventral
posteromedial nucleus of the thalamus.
The axons of these cells travel through the internal capsule to the postcentral gyrus ( area 3, 2
and 1 ) of the cerebral cortex

MOTOR COMPONENT OF THE TRIGEMINAL NERVE

The motor nucleus receives corticonuclear fibres from both cerebral hemispheres.
It also receives fibres from the reticular formation , the red nucleus, the tectum, and the
medial longitudinal fasciculus.
It also receives fibres from the mesencephalic nucleus to form a monosynaptic reflex arc.
The cells of the motor nucleus give rise to the axons that form the motor root.
The motor nucleus supplies the muscles of mastication, the tensor tympani, the tensor veli
palatini, the myelohyoid and the anterior belly of the digastric muscle.

THE TRIGEMINAL GANGLION :-

Also known as Gasserian ganglion, or semilunar ganglion, is a sensory ganglion of
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the trigeminal nerve that occupies a cavity (Meckel's cave) in the dura mater, covering
the trigeminal impression near the apex of the petrous part of the temporal bone.
It is somewhat crescentic or semilunarin shape, with its
convexity directed anteriomedialy.
The three divisions of the trigeminal nerve emerges from this convexity.

ASSOCIATED ROOTS AND BRANCHES:-

The central processes of the ganglion cells form the large sensory root of the trigeminal
nerve ,which is attached to pons at its junction with the middle cerebellar peduncle.
The peripheral processes form the three divisions of the trigeminal nerve.
The small motor root of the trigeminal nerve is attached to the pons superomedialy to the
sensory root.
It passes under the ganglion from its medial to the lateral side and joins the mandibular nerve
at the foramen ovale.

RELATIONS:-
MEDIALY- Internal carotid artery
posterior part of cavernous sinus

LATERALY-Middle meningeal artery

SUPERIORLY- Parahippocampal Gyrus

INFERIORLY-Motor root of trigeminal nerve

greater petrosal nerve
apex of the petrous temporalbone
foramen lacerum

DIVISIONS AND BRANCHES OF TRIGEMINAL NERVE

There are three main branches of the trigeminal nerves.
Ophthalmic nerve – sensory only
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Maxillary nerve – sensory only

Mandibular nerve – sensory and motor.

Trigeminal nerve is the largest cranial nerve.

It is a mixed nerve.
Composed of a small motor root and a considerably larger sensory root.
The sensory root contains 170000 fibres and the motor root
contains 7700 fibres.

Ophthalmic nerve :
A sensory nerve passes through the superior orbital fissure and supplies the eyeball,
conjunctiva, lachrymal gland and sac, nasal mucosa, frontal sinus, frontal sinus, external
nose, upper eyelid, forehead and scalp.

Branches
Tentorial nerve
Lachrymal nerve
Frontal nerve – supraorbital nerve
supratrochlear nerve
Nasociliary nerve
Short ciliary nerves
Long ciliary nerves
Infratrochlear nerve
Anterior and posterior ethmoidal nerves.
Lacrimal nerve:
Smallest of main ophthalmic branches

Enters the orbit through the lateral part of the superior orbital fissure

Runs along the upper border of the rectus lateralis with the lacrimal artery

Receives a twing from the zygomaticotemporal branch of maxillary nerve.which contains

lacrimal secretomotor fibres
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Supplies the lacrimal gland and the adjoining conjunctiva.

Pierces the orbital septum.
Ends in the upper eyelid, where it joins filaments of the facial nerve

FRONTAL NERVE:
Largest branch of the ophthalmic division.
Enters the orbit by the superior orbital fissure.
Divides midway between the apex and the base of the orbit into two branches:
Supratrochlear
Supra orbital

SUPRATROCHLEAR BRANCH:
Runs anteromedially,passing above the troclear.

Supplies a descending filament to the infratrochlear branch of

nasociliary nerve.

Then it emerges between the trochlea and the supraorbital foramen and supplies
- conjunctiva
- skin of the upper eyelid
- skin of the lower forehead near the midline

THE SUPRAORBITAL BRANCH

Proceeds between the levator palpabrae superioris and the orbit al roof

Transverses the supraorbital foramen, supplying the upper eyelid and conjunctiva

Then ascends on the forehead with the supraorbital artery,dividing into medial and lateral
branches,which supply the skin of the scalp till the lambdoid suture

The main nerve and both branches also supply the mucosa of the frontal sinus and the
pericranium
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NASOCILIARY BRANCH
Intermediate in size between frontal and lacrimaL
Deeply placed in the orbit

Enters the orbit through the annular tendon lying between the two rami of the oculomotor
nerve

Runs obliquely below the rectus superior to the medial orbital wall

Here, as anterior ethmoidal nerve, it transverse the anterior ethmoidal foramen and canals

Enters the cranial cavity from where it descends into nasal cavity through a slit lateral to
crista galli, supplies two internal nasal branches

At the lower border of the nasal bone it emerges as the external nasal nerve and supplies the
skin of the nasal ala, apex and vestibule

The nasociliary nerve connects with the ciliary ganglion and has long ciliary, intratrochlear
and posterior ethmoidal branches

Two or three long ciliary nerve branch from nasociliary runs forward
between sclera and choroid and supply the ciliary body, iris, cornea

The infratrochlear branches from nasociliary near the anterior ethmoidal foramen and
supplies the skin of the eyelids and the side of the nose, conjunctiva, lacrimal sac and
lacrimal caruncle

The posterior ethmoidal nerve leaves the orbit by the posterior ethmoidal foramen and
supplies the ethmoidal and the sphenoidal sinuses

Maxillary nerve:
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It leaves the trigeminal ganglion between the ophthalmic and mandibular divisions as a flat
plexiform band
Passes slightly medial to lateral wall of cavernous sinus
Leaves the cranium through foraman rotandum, which is located in the greater wing of
sphenoid bone.
It supplies the cheeks, upper gums, upper teeth and lower eyelids.

Branches:
Meningeal branch
Zygomatic nerve
Posterior superior alveolar branches
Infraorbital nerve
Greater palatine nerves
Lesses palatine nerve
Lesser palatine nerves
Posterior superior lateral nasal branches
Nasopalatine nerve
Pharyngeal nerve

Meningeal nerve:
Also known as nervus meningeus medius.
It lies within the cranium.
It receives a ramus from the internal carotid sympathetic plexus and accompanies the middle
meningeal artery to supply the duramater

Branches through pterygopalatine fossa:

ZYGOMATIC NERVE:-
Starts in the pterygopalatine fossa.
Enters the orbit through the inferior orbital fissure.

Divides into two branches.

Zygomaticcotemporal: supplying sensory innervation to skin on the side of the
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forehead.
Zygomaticofacial: supplying the skin on the prominence of the cheek.

Before leaving the orbit the zygomatic nerve communicates with the lacrimal nerve of the
ophthamic division which carries secretory fibres from pterygopalatine ganglion to lacrimal
gland.

POSTERIORSUPERIORALVEOLARNERVE:

It descends from the main trunk of the maxillary division in the ptergopalatine fossa.

Through the pterygopalatine fossa,it reaches the inferior temporal surface of the maxilla.

From here it enters maxilla through the psa canal

Travel down the posteriolateral wall of the maxillary sinus.

Provides sensory innervation to the mucous membrane of the sinus.

Continuing downward it provides sensory innervation to the alveoli,periodontal

ligaments,and pulpal tissues of the maxillary 3rd ,2nd and 1st molar.

The Pterygopalatine Nerve:

This nerve turns straight downward after it has left the trunk of the second division
The pterygopalatine ganglion is attached to the medial side of the nerve

Branches of pterygopalatine nerve includes those that supply four areas:-

1.orbit
2.nose – a) superior posterior nasal
medial
lateral
b) nasopalatine
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3.palate- a) greater (anterior)

b)lesser (middle & posterior)
4.pharynx

The orbital branches supply the periosteum of the orbit.

The superior posterior nasal branches are given off at the level of the ganglion.

Enter the nasal cavity through the sphenopalatine foramen.

Lateral branches of superior posterior nasal nerve supply upper and middle conchae.

Medial branches of the nerve pass over the roof of the nasal cavity to the nasal septum,one of
the medial branches is distinguished by its great length and by its diagonal course downward
and forward along the nasal septum,it is called the nasopalatine nerve.

The nasopalatine nerve gives off branches to the anterior part of the nasal septum and the
floor of the nose

Enters the incisive canal , passes into oral cavity via the incisive foramen, located in the
midline of the palate about 1cm posterior to the maxillary central incisors.

The right and left nasopalatine nerves emerge together through this foramen and provide
sensation to the palatal mucosa in the region of premaxilla ( canine to central incisor)

GREATER PALATINE NERVE:

Emerges on the hard palate through the greater palatine foramen (usually located about 1cm
towards the palatal
midline, just distal to the second molar)
The nerve courses anteriorly supplying sensory innervation to the palatal soft tissues and
bone as far as the first premolar, where it communicates with the terminal fibres of the
nasopalatine nerve.
It provides sensory innervation to some parts of soft palate
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The Middle Palatine Nerve:

Emerges from the lesser palatine foramen along with the posterior palatine nerve .
Provides sensory innervation to the mucous membrane of soft palate

The posterior palatine nerve:

Innervates the tonsillar region.

THE PHARYNGEAL BRANCH:

It is a small nerve
Passes through the pharyngeal canal and is distributed to the mucous membrane of the nasal
part of the pharynx posterior to the auditory tube.

BRANCHES IN THE INFRAORBITAL CANAL:

The nerve enters the orbit through the inferior orbital fissure, and is then called the infra
orbital nerve passing through the infra orbital canal.

Within the canal it gives of two branches:

1.middle superior 2.anterior superior

alveolar branch alveolar branch

THE MIDDLE SUPERIOR ALVEOLAR NERVE (MSA):

Arises from the infra orbital nerve.

Provides sensory innervation to two maxillary premolars and perhaps to the mesiobuccal
root of the first molar and the periodontal tissues, buccal soft tissues and bone in the premolar
region.
Traditionally it has being stated that the MSA nerve is absent in 30% to 54% of individuals.
In its absence the usual innervations are provided by either the PSA or the ASA nerve, most
frequently the latter.
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THE ANTERIOR SUPERIOR ALVEOLAR NERVE (ASA):

It is a relatively larger branch

Given off from the infraorbital nerve at approximately 6 to 10mm before the latter exit from
the infraorbital foramen
It provides pulpal innervation to the:
central and lateral incisors
canine
periodontal tissues
buccal bone
mucous membrane of these teeth.

BRANCHES ON THE FACE:

The infraorbital emerges through the infraorbital foramen onto the face to divide into its
terminal branches:

1) the inferior palpebral:- supplying the skin of the lower eyelid

2) the external nasal branch:- providing sensory innervation to skin of lateral part of the nose
3) the superior labial branch:- supplying the skin and mucous membrane of the upper lip.

Mandibular nerve

Largest of the three divisions and has a motor nerve and sensory nerve.
The sensory root originates from trigeminal ganglion whereas the motor root originates in the
pons and medulla ablongata It passes through the foramen ovale.

BRANCHES OF THE MANDDIBULAR NERVE:

1.Undivided nerve
2.Divided nerve
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Anterior
Posterior

Undivided Nerve
1.Nervus spinosus
2.Nerve to medial pterygoid muscle

Divided Nerve

1. anterior division- nerve to lateral pterygoid

nerve to masseter muscle
nerve to temporal muscle
buccal nerve

2. posterior division- auriculotemporal nerve

lingual nerve
mylohyoid nerve
inferior alveolar nerve- incisive
mental

BRANCHES OF THE UNDIVIDED NERVE:

On leaving the foramen ovale the main undivided trunk gives two branches during its 2-3mm
course ie the meningeal branch and the nerve to medial pterygoid

THE MENINGEAL BRANCH

Also called as Nervus Spinosus.
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It re-enters the cranium through the foramen spinosum along with the middle meningeal
artery to supply the duramater.

NERVE TO MEDIAL PTERYGOID

It is a motor nerve to medial pterygoid muscle

It supplies one or two filaments which passes through otic ganglion to supply tensor tympani
and tensor veli palatini.

BRANCHES FROM ANTERIOR DIVISION:

Provides motor innervation to the muscles of mastication

sensory innervation to the mucous membrane of the cheek and buccal mucous membrane of
the mandibular molars

The anterior division is smaller than the posterior division

It runs forward under the lateral pterygoid muscle for a short distance and then reaches the
external surface of that muscle by passing between its two heads, from this point it is known
as buccal nerve.
Under the lateral pterygoid nerve,it gives off some branches, i.e.
The deep temporal nerve- to the temporal muscle
The masseter nerve- providing motor innervation to masseter muscle
Lateral pterygoid nerve- providing motor innervation to the lateral pterygoid muscle

THE BUCCINATOR NERVE:

Also known as long buccal nerve

Usually passes between the two heads of the lateral pterygoid

Reaches the external surface of the muscle

follows the inferior part of the temporal muscle
emerges under the anterior border of the masseter muscle
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At the level of occlusal plane of the mandibular 3rd and 2nd molar

Crosses in front of the ramus

Enters the cheek through buccinator muscle

Provides sensory innervation to:

skin over the anterior part of buccinator
buccal gingiva of mandibular molars
mucobuccal fold in that region

The bucaal nerve does not innervate the buccinator muscle,the facial nerve does.

THE POSTERIOR DIVISION

Larger division
Mainly sensory

Divides into
1.Auriculotemporal
2.Lingual
3.Alveolar

AURICULOTEMPORAL NERVE

IT HAS TWO ROOTS:

encircles the middle meningeal artery

runs back under lateral pterygoid on the surface of tensor veli palatini to pass between the
sphenomandibular ligament and the neck of the mandible

then lateraly behind the the temporomandibular joint in relation with the upper part of the
parotid gland
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emerging from behind the joint it ascends posterior to the superficial temporal vessels over
posterior root of the zygoma divides into superficial temporal branches.

BRANCHES OF AURICULOTEMPORAL NERVE:

a) two anterior auricular branch-supply the skin of tragus and sometimes small part of
adjoining helix
b)two branches to external acoustic meatus-supply skin of meatus and the tympanic
membrane

The articular branch- supplying the temporomandibular joint

Superficial temporal branch- supply skin in the temporal region and connects with the facial
and zygomaticotemporal nerves

COMMUNICATIONS-
It communicates with facial nerve providing sensory fibres to the skin over the areas of
innervation of motor branches of facial nerve
It communicates with the otic ganglion providing sensory,secretory and vasomotor fibres to
parotid gland

THE LINGUAL NERVE:

Second branch of the posterior division of mandibular nerve

Runs between the tensor veli palatini and lateral pterygoid,where it is joined by chorda
tympani branch of facial nerve from here

It decends to rest between the ramus and medial pterygoid muscle in the pterygomandibular
space

It runs anterior and medial to the inferior alveolar nerve whose path is parallel to it.

It then continues to reach the side of the base of the tongue slightly below and behind the
mandibular 3rd molar.
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Here it lies just below the mucous membrane in the lateral lingual sulcus.

It then proceeds anteriorly across the muscles of the tongue

Looping medial to submandibular duct (wharton’s duct) to deep surface of submandibular

and sublingual gland where it breaks up into terminal branches

SUPPLY OF LINGUAL NERVE

Supplies the mucosa of the floor of the mouth
lingual gingivae
Mucosa of anterior two third of the tongue
Also carries postganglionic fibres from submandibular ganglion to sublingual and anterior
lingual glands

APPLIED ANATOMY
Lingual nerve is at great risk during surgical removal of impacted third molar
During removal of submandibular salivary gland,during which the duct must be dissected
from lingual nerve.

INFERIOR ALVEOLAR NERVE

Largest branch of the mandibular division

Descends medial to the lateral pterygoid muscle and lateroposterior to lingual nerve

Passes between the sphenomandibular ligament and the mandibular ramus to enter the
mandibular canal via mandibular foramen

Through out its path it is accompanied by inferior alveolar artery and inferior alveolar vein

Nerve travels anteriorly in the canal till it reaches the mental foramen.

THE INCISIVE NERVE

Continues forward in the bony canal giving off branches to:
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premolar
canine
incisors
associated labial gingiva

THE MENTAL NERVE

Exists the canal through the mental foramen between and just below the apices of the
premolar,and divides into three branches that innervates:
skin of the chin
skin of the lower lip
buccal mucous membrane from
second premolar to the midline
i.e central incisor region.

THE MYLOHYOID NERVE

Just before entering the mandibular canal, the inferior alveolar nerve gives off a small
mylohyoid branch

It pierces the sphenomandibular ligament and enters a shallow groove on medial surface of
mandible

Follows a course roughly parallel to inferior alveolar nerve

passes below the origin of mylohyoid muscle
lies superficial to the surface of mylohyoid muscle
It is a mixed nerve
Provides motor innervation to:
mylohyoid and anterior belly of digastric
sensory fibres to inferior and anterior surfaces of mental protuberance
mandibular incisors (sometimes)
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GANGLIA ASSOCIATED WITH THE TRIGEMINAL NERVE

1.CILLIARY GANGLION

connected with nasocilliary nerve by ganglionic branches in orbit, non synapsing

sensory for orbit

2.PTERYGOPALATINE GANGLION:
connected to maxillary nerve in infratemporal fossa
sensory to orbital septum, orbicularis and nasal cavity, maxillary sinus , palate , nasopharynx.

3. OTIC GANGLION: lies between trunk of mandibular nerve and tensor palatini , nerve to
med pterygoid passes through but does not synapse in the ganglion.
4.SUBMANDIBULAR GANGLION: related to lingual nerve,rest on hypoglossus
supplies post erior ganglionic Parasympathetic secretomotor fibres to submandibular and
sublingual gland.

TRIGEMINAL NERVE EXAMINATION:

SENSORY:
Light touch is tested in each of the three divisions of the trigeminal nerve and on each side of
the face using a cotton wisp or tissue paper.

The ophthalmic division is tested by touching the forehead, the maxillary division is tested by
touching the cheeks, and the mandibular division is tested by touching the chin. Be careful
not to test the mandibular division too laterally, as the mandible is innervated by the great
auricular nerve (C2 and C3).
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Initially test the sensory branches by lightly touching the face with a piece of cotton wool
followed by a blunt pin in three places on each side of the face:

 around the jawline,

 on the cheek and,

 on the forehead

Corneal reflex is conducted along with the facial nerve section of the test. Note the sensory
innervation of the cornea is provided by the trigeminal nerve while the motor innervation for
blinking the eye is provided by the facial nerve. Do this by lightly touching the cornea with
the cotton wool. This should cause the patient to shut their eyelids.

MOTOR:

Muscles of mastication (temporalis, masseter) should be inspected for atrophy. Palpate the
temporalis and masseter as the patient clenches the jaw.

The pterygoids can be tested by asking the patient to keep the mouth open against resistance,
and move from side to side against resistance.

A jaw jerk reflex can be tested by placing a finger over the patient's chin and then tapping the
finger with a reflex hammer. Normally the jaw moves minimally.

APPLIED ANATOMY :-

 Sensory disturbances in the distribution of TN are common after facial injury and are due
to stretching, compression or disturbance of the nerve concerned.

 Damage of nasociliary branch = Loss of cranial reflex

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 Sensory distribution of TN causes Headache in –

common cold

boils & sinusitis

infection & inflammation of teeth & gums

Eye problems
VON FREY'S SYNDROME

• Damage to the Auriculotemporal nerve in the condyler neck causes facial flushing &
sweating instead of salivatory response at the meal time

PORT WINE STAINS

• Congenital cutaneous naevi on face present on the areas supplied by one or more
divisions of TN

NERVE INJURY:
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Neuropraxia First degree No axonal Loss of sensation,rapid recovery

damage,no demyelination,no (days to weeks), no microneurosurgery

neuroma

Axonotmesis 2nd ,3rd,& More axonal Loss of sensation, slow incomplete

4th degree damage,demyelination,possible recovery
neuroma (weeks to months), microneurosurgery

Neurotmesis 5th degree Severe axonal damage,epineural Loss of sensation, spontaneous

discontinuity,neuroma recovery is
formation unlikely to occur, microneurosurgery.

TRAUMATIC NEUROMA:

 Amputation neuroma

- soft tissue regions

(lingual nerve)

 Neuroma in continuity

- occurs in bony canal

- inferior alveolar nerve

- infra orbital nerve

 lateral exophytic

lateral adhesive
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TRIGEMINAL NEURALGIA:-

also known as Fothergill’s disease

Tic douloureux (painful jerking)

it is defined as, sudden ,usually ,unilateral ,severe ,brief ,stabbing , lancinating , recurring
pain in the distribution of one or more branches of trigeminal nerve.

Mean age: 50 y onwards

Female predominance (male : female = 1:2 ~2:3)

Pathogenesis of trigeminal neuralgia

It is usualy idiopathic.
The probable etiologic factors are:-

Intra cranial tumors:-Traumatic compression of the trigeminal nerve by neoplastic

(cerebellopontine angle tumor) or vascular anomalies eg arteriovenous malformations

Infections :- granulomatous and non granulomatous infections involving 5th cranial nerve.
postherpetic neural
Demyelinating conditions
Multiple sclerosis
Petrous ridge compression
Intracranial vascular abnormalites

Pulsation of vessels upon the trigeminal nerve root do not visibly damage the nerve.
However, irritation from repeated pulsations may lead to changes of nerve function, and
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delivery of abnormal signals to the trigeminal nerve nucleus. Over time, this is thought to
cause hyperactivity of the trigeminal nerve nucleus, resulting in the generation of TN pain.

General characteristics

Incidence:- seen in about 4 in 100000 persons

Age of occurrence:- 5th to 6th decade
Sex predilection:-female predisposition
Side involved more frequently:-right side
Division of trigeminal nerve involve; most commonly
mandibular > maxillary >ophthalmic

Clinical characteristics:-

1.sudden
2.unilateral
3.intermittent paroxysmal
4.sharp shooting
5.lancinating shock like pain elicted by slight touching
superficial trigger points which radiates across the distribution of one or more branches of
the trigeminal nerve
6.pain rarely crosses the midline
7.pain is of short duration and last for few seconds to minutes
8.in extreme cases patient has a motionless face called the frozen or mask like face
9.presence of intraoral or extraoral trigger points
10.Provocated by obvious stimuli like
Touching face at particular site.
Chewing
Speaking
Brushing
Shaving
Washing the face
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11.The characteristic of the disorder being that the attacks do not occur during sleep.

DIAGNOSIS:-

CLINICAL EXAMINATION with HISTORY is mandatory

Response to treatment with tablet of carbamazepine is univeral
Injections of local anaesthetic agents into patients trigger zone gives temporarily relief from
pain.

TREATMENT:

Medical treatment
Surgical treatment:-
Peripheral injections
Peripheral neurectomy
Cryotherapy
Peripheral radiofrequency
Neurolysis(thermocoagulation)
Gasserian ganglion procedures

HERPES ZOSTER OPHTHALMICUS:-

Caused by Varicella zoster

Predilection for nasociliary branch of ophthalmic division of the trigeminal nerve
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CLINICAL FEATURES:-

Cutaneous lesions:-
Rash
Vesicle
Pustule crust permanent scar
Ocular lesions:-
Eyelid:- Perorbital pain

Oedema

Hyperasthesia

Conjunctivitis

Scleritis

Corneal scarring

Glaucoma

TREATMENT:-

Acyclovir 800mg 5 times /day within 4 days of onset of rash

Analgesics
Antibiotic ointments
Systemic steroids 60mg/day
Corneal grafting
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WALLENBERG SYNDROME:-
a stroke which causes loss of pain/temperature sensation from one side of the face and
the other side of the body.

ETIOLOGY:-
In the medulla, the Ascending Spinothalamic Tract (which carries pain/temperature
information from the opposite side of the body) is adjacent to the Descending
Spinal Tract of the fifth nerve (which carries pain /temperature information from
the same side of the face)
A stroke cuts off the blood supply to this area
Destroys both tracts simultaneously.
Results in loss of pain/temperature sensation in a unique “checkerboard” pattern (ipsilateral
face, contralateral body)
Characteristic diagnostic feature.

CAVERNOUS SINUS SYNDROME

• Multiple cranial neuropathies

• Exophthalmos, ocular motor defects, sensory loss in V1 and / or V2.
• Pupils may be spared or involved.

causes: bacterial thrombophlebitis

actinomycosis

rhinocerebellar mucormycosis

aspergillosis

tolosa hunt syndrome

neoplasms

vascular lesions
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GRADENIGOSSYNDROME

 Petrous bone osteitis due to otitis media

 Characterized by I/L trigeminal N palsy (Va, Vb)

retro orbital pain

I/L sixth N palsy.

NASOPHARYNGEAL CARCINOMA
Source –
Maxillary Nerve Involvement in Nasopharyngeal carcinoma, American Journal of
Roentgenology
AJR:167, November 1996
V.F.H.Chong1 and Y.F. Fan

RAEDERS PARATRIGEMINAL SYNDROME:

 Oculosympathetic paresis with pain in distribution of trigeminal Nerve.

Pt. with episodic chronic pain

Pain and headache

 Trigeminal hyperasthesia seen in area supplied by post ganglionic fibers.

HYPERAESTHESIA OVER ALL OR PART OF DISTRIBUTION OF NERVE –

Causes –
1. Vascular lesion
2. Multiple sclerosis
3. Herpes infection
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NEUROTROPHIC KERATITIS
 Occurs due to partial or complete corneal anaesthesia due to loss of sensory
innervation by the trigeminal N.
 There is impaired response to corneal microtrauma as a result of impaired
regeneration and healing of corneal epithelium
 Causes: infections - HSV, VZV, leprosy

traumatic V N injury

ablation of gasserian ganglion

chemical burns

topical anaesthatic abuse,

betablockrs,

NSIDS

contact lens wear

systemic: DM, stroke, brainstem

haemorrhage, aneurysm

congenital

CONCLUSION:
Trigeminal nerve, its anatomic course and branches are very important from a dentist point of
view.
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Disorders of Trigeminal nerve are not rare ,knowing about it will help in formulating
appropriate diagnosis and treatment thus achieving the best possible recovery of Trigeminal
nerve function.
Nerve blocks given for carrying various dental procedures involves the various branches of
Trigeminal nerve,hence to avoid any complications ,one needs to have a knowledge about
the course and branches of the nerve .

REFERENCES:-

Anatomy head and neck( B.D Chourasia)

Gray’s Anatomy
Anatomy for dental Students( A.S. Moni)
Handbook of local anaesthesia by stanley malamed
Textbook of oral and maxillofacial surgery (neelima Anil Malik)
Burkets textbook of oral medicine
Harrisson text of internal medicine
journal of morphology
journal of clinical anatomy
JIAOMR
BMC JOURNAL
NEURORADIOLOGY JOURNAL
CED
British Journal of Neurosurgery
PRACTICAL NEUROLOGY
Romanian Journal of Morphology & Embryology