V A connective tissue sheath called EPINEURIUM surrounds

each nerve. Each bundle of nerve fiber is called as fasciculus

and is surrounded by a layer of connective tissue called as
PERINEURIUM.
V Within the fasciculus, each individual nerve fiber is
surrounded by connective tissue called as the
ENDONEURIUM.
V A nerve fiber may also contain blood vessels enclosed in its
connective tissue wrappings.
A nerve can be:-
V Motor or sensory or mixed
V Cranial or spinal
V Myelinated or non-myelinated
V MOTOR NERVE:-a nerve that transmits impulses from
central nervous system to muscles or organs. Motor nerves
cause voluntary and involuntary muscle contractions and
stimulates the glands to secrete hormones.
V SENSORY NERVE:-It is the nerve that receive sensory
stimuli, such as how something feels and if it is painful.
V CRANIAL NERVE:-These are the nerves that emerge directly from
the brainstem in contrast to the spinal nerves which emerge from
the fragments of spinal cord.Except the tenth and eleventh cranial
nerve,all of them serve the motor and sensory systems of head
and neck.There are thirteen cranial nerves:-
V Olfactory
V Optic
V Occulomotor
V Trochlear
V Trigeminal
V Abducens
V Facial
V Vestibulocochlear or auditory vestibular
V Glossophrangeal
V Vagus
V Acessory nerve or spinal acessory nerve
V Hyposlossal nerve
V Cloacal nerve
V SPINAL NERVE:-It generally refers to mixed spinal nerve
which is formed from the roots that come out of spinal
cord.Spinal nerve is the bit that pass out of the vertebrae
through the intervertebral foramen.There are 31 pairs of
spinal nerves in humans.
V MYELINATED NERVE:-a peripheral nerve whose axons are
surrounded by layers of Schwann cell membranes that form
the myelin sheath.They are also called as Medullated nerves.
V NONMYELINATED NERVE:-They are found in both
CNS and PNS. Axons are enclosed in simple clefts of
oligodendrocytes.
V In a non myelinated nerve fiber:-
V First a spot of nerve fiber is depolarized
V As the space b/w axolemma and schwann cell membrane
communicates with extracellular fluid(ECF) throughout the
length of axon , entry of Na+ and exit of K+ starts
V Once action potential is developed at a point it causes potential
drop to develop at neighboring regions and when the
membrane potential drop reaches a critical level in neighboring
regions there is explosive entry of Na+ from outside.
V In a myelinated nerve:-
V Entry of Na+ or K+ can occur only at nodes of ranvier and not
at any other point because of presence of myelin sheath.
V As a result , sharp drop of membrane potential occurs only at
nodes of ranvier due to which pulses appear to jump from
node to node. This makes the velocity of conduction in
myelinated nerve fibers much more higher than in the
nonmyelinated nerve fibers. This conduction is called as
SALTATORY CONDUCTION.
V largest cranial nerve
V Mixed nerve

R
  
V Root of this nerve travels anteriorly and laterally and reaches
the edge of pyramid of temporal bone.
V At the edge of pyramid it enters a space that extends
anteriorly and inferiorly b/w the layers of duramater,which
widens anteriorly to accommodate semilunar or gasserian
ganglion which is crescent shaped
V Sensory root enters the concave margin and from the
convexity arises the three branches of trigeminal nerve.
V Ophthalmic nerve(V1)
V Maxillary nerve(V2)
V Mandibular nerve(V3)
V It is the first division of trigeminal nerve.
V It splits immediately after reaching the orbit into three main
branches,namely:-
V Nasociliary branch(internal branch)
V Frontal branch(intermediate branch)
V Lacrimal branch(external branch)
V It follows the border of the orbit and
sends a communicating branch
through the ciliary ganglion,which is
sometimes wrongly called as sensory
root of ciliary ganglion.
V It has no relation to do with cells of
ciliary ganglion and its fibres
continue to the eyeball.
V Next,nasociliary nerve gives two or
three long ciliary nerves that run
directly into the eyeball.
V After this nasociliary nerve follows
the upper border of medial rectus of
eye where it gives a branch,ethmoid
nerve,which passes through the
anterior ethmoid foramen into
cranial cavity and passes over the
anterior end of cribriform plate and
passes into the nasal cavity.it is
extradural.
V In the nasal cavity ethmoid nerve divides into medial and
lateral nasal branches.They supply the mucous membrane on
lateral wall and nasal septum.
V External nasal branch runs downward on the inner surface of
nasal bone and turns into skin of nasal bridge through a
small opening.
V Terminal branch of nasociliary nerve is the infratrochlear
nerve.It runs anteriorly and passes below the
trochlea,superior oblique and emerges from the orbit into
skin at inner corner of eye.
V Infratrochlear nerve exchanges fibres with supratrochlear
nerve which is a branch of frontal nerve.
V It is the intermediate and
largest branch of the
ophthalmic nerve.
V It curves around lateral
border of superior rectus
muscle and reaches the
superior surface and then on
the levator of the upper
eyelid.
V It continues b/w the roof of
orbit and levator as
supraorbital nerve which
divides into three
branches,namely:-
V Medial and lateral branches
of supraorbital nerve
V Supratrochlear nerve
V Lateral branch is largest of all and continues anteriorly as
supraorbital nerve and emerges on the skin of forehead
through supraorbital foramen or notch.
V It supplies the greater part of lateral forehead and skin of
scalp upward and backward to vertex.
V Medial branch turns slightly medially from its origin.It
reaches the forehead through frontal notch of superior
orbital rim and supplies medial area of skin of forehead.
V Supratrochlear nerve is the most medial and smallest branch.
V It crosses the trochlea of the superior oblique muscle and
reaches the upper eyelid near inner corner of eye where it
exchanges fibres with the infratrochlear nerve and supplies
the skin of upper lid and nasal root.
V It is the external branch of
ophthalmic nerve
V In its course towards
lacrimal gland ,it receives a
branch from zygomatic
nerve of second division.
V After passing through
lacrimal gland ,the nerve
reaches the upper eyelid
near the outer corner of the
eye and supplies lateral part
of upper eyelid and small
adjacent area of skin.
V It is the second division of Trigeminal nerve.
V It leaves the skull through foramen rotundum and opens into
pterygopalatine fossa.
V Branches of maxillary nerve:-
V Branches in middle cranial fossa
V Middle meningeal nerve

V Branches in pterygopalatine fossa

V Zygomatic nerve
V Pterygopalatine nerve
V Posterior superior alveolar nerve
V Branches in ifraorbital groove or canal
V Middle superior alveolar nerve
V Anterior superior alveolar nerve

V Terminal branches
V Inferior palpebral
V Lateral nasal
V Superior labial
V It is the external branch of
maxillary nerve and often appears
to be a branch of infraorbital
nerve.
V In the orbit it follows the lateral
edge of orbit floor anteriorly and
laterally.
V It sends a branch to lacrimal gland
upwards.
V After releasing this
branch,zygomatic nerve enters
zygomatico-orbital foramen in
orbital surface of zygomatic bone.
V One branch emerges at anterior or
malar surface of zygomatic bone,
zygomatico-facial nerve and
supplies skin over the height of
cheek.
V Second branch emerges at posterior or temporal surface
of frontal process ,zygomatico-temporal nerve. It supplies
small anterior area of skin in temporal region.
V Pterygopalatine ganglion is attached to its medial side.
V It enters the ganglion after a course of only 2-3mm
V It has only topographic connection with the ganglion.
V It gives posterior superior nasal branch at the level of
ganglion which enters the nasal cavity through
sphenopalatine foramen behind middle nasal concha and
below the body of sphenoid.
V Lateral branches of superior posterior nasal nerve supply
larger posterior part of upper and middle concha.
V Medial branches pass over roof of nasal cavity to the nasal
septum.One of this branch is distinguished by its great
length and diagonal course forward and downward along
nasal septum,it is nasopalatine nerve.
V Nasopalatine nerve suplies branches to septal mucosa and
then passes through incisive canal into oral cavity.
V Immediately after entering incisive canal it exchanges fibres
with anterior superior alveolar nerve and may participate in
innervation of upper central incisor.
V In the incisive canal,right and left palatine nerves approach
each other and enter the oral cavity through unpaired
incisive foramen.
V They supply small anterior area of palatine mucosa behind
the incisor teeth,which is diagramatically bounded by a line
from one canine to the other.
V Main part of pterygopalatine nerve continues below the
ganglion in a downward course through the entire height of
pterygopalatine fossa and then through pterygopalatine
canal.
V Two or three branches leave the palatine nerve in
pterygopalatine canal to enter the nasal cavity.These are
inferior or posterior nasal nerves and supply inferior nasal
concha and middle and inferior nasal meatus
V Before reaching the lower oral end of pterygopalatine
canal,palatine nerve divides into one large and one or two small
branches.
V Larger branch,anterior palatine nerve,enters the oral cavity
through major palatine foramen and turns anteriorly.It soon splits
into numerous branches that spread fanwise.anteriorly,laterally
and medially and supply mucosa of hard palate up to canine line.
V The smaller middle and posterior palatine nerves emerge into oral
cavity through lesser palatine foramen and supply tonsil and soft
palate.
V Posterior superior alveolar nerve(PSA)which arises in
infratemporal fossa before it reaches the maxillary
tuberosity.It runs downwards,anteriorly and laterally to reach
the convex surface(anterior)of maxilla at about center of the
surface.
V At a variable distance PSA divides into two or three branches.
V Sometimes division occurs before the nerve reaches the
maxillary tuberosity,sometimes on posterior surface of
maxilla(most common) and sometimes after it has entered
the posterior superior alveolar foramen
V If the division takes place at the surface of maxilla,alveolar
nerves enter two or three small openings that lead into
narrow posterior superior alveolar canal into posterolateral
wall of sinus.
V In these canals the nerve reaches the base of alveolar
process.
V It is the intermediate branch of maxillary nerve
V It constitutes the course of main trunk anteriorly and slightly
laterally.
V It passes through pterygomaxillary fissure into anteromedial
corner of infratemporal fossa and leaves it through inferior
orbital fissure,through which it enters the orbit.Here it runs
in the infra orbital groove at the orbital floor.
V Anteriorly at some distance from posterior border of
orbit,infraorbital groove is roofed to form infraorbital canal
which leads the nerve to infraorbital fissure.
V After leaving the infraorbital canal it splits into terminal
branches.
V It gives two branches before leaving through infraorbital
foramen.
.
Applied anatomy-
V This nerve gets injured during trauma to the
zygomatico-orbital surface.
V This nerve should be preserved in vestibular maxillary
approach as it is present 7-10 mm inferior to the
infraorbital rim just medial to zygomaticomaxillary
suture
Middle superior alveolar
nerve:-

V Middle superior alveolar

branch of infraorbital
nerve.It is enclosed in
narrow canal,travels first in
roof of maxillary sinus and
then in its lateral walls to
converge with posterior
superior alveolar nerve
towards the base of alveolar
process.
V This nerve is absent
frequently(60%) and its
fibres are incorporated in
posterior or anterior
superior alveolar nerve.
Anterior superior alveolar nerve:-

V Anterior superior alveolar nerve

leaves the infraorbital nerve in
infraorbital canal as one common
branch or two or three small
branches.
V The canal for this nerve is
situated in anterior wall of sinus.
V First the nerve runs downward
and laterally and then curve
medially and divides into two sets
of branches below infraorbital
foramen.
V Anterior set continues inferior
and medial course to
inferomedial circumference of
piriform or anterior nasal
aperture.
V The alveolar branches continue
into most medial part of alveolar
process.
V Posterior set of branches of anterior
superior alveolar nerve turns from a
point of divergence backward and
reaches the alveolar process in the
region of canine.
V In the base of alveolar process
superior alveolar nerves form a
plexus,the superior dental plexus.
V The terminal branches of superior
alveolar nerves emerge from this
plexus in two sets that accompany
the corresponding arteries.Each
nerve enters the apical foramen and
divides into branches.
V Second group of terminal branches
are perforating,interdental or
interradicular nerves.It runs through
entire height of interdental septum
and during this course numerous
branches to PDL are given.
V At the crest of the septum interdental nerves emerge into
gingiva and supply the interdental papilla and labial or
buccal gingiva.They end in periodontal ligament at furcation
of roots.
V Terminal branches of infraorbital nerve itself spread fanwise
from infraorbital foramen towards lower eyelid(inferior
palpaberal),nose(lateral nasal) and upper lip(superior labial)
V It is the largest division of trigeminal nerve and is a mixed
nerve.
V Otic ganglion is attached to its medial surface.
V At the origin motor and sensory branches cannot be entirely
separated.
V Branches from undivided nerve
V Nervous spinosus
V Nerve to the medial pterygoid
V Branches from anterior division
V Branch to lateral pterygoid
V Branch to masseter muscle
V Branch to temporalis
V Branches from posterior division
V Auriculotemporal
V Inferior alveolar
V lingual
Motor nerves for the muscles of mastication are given in
following way:-
MASSETERIC NERVE:-
V It leaves the mandibular nerve on its lateral surface close to
cranial base.
V It runs laterally b/w infratemporal surface of greater wing of
sphenoid and lateral pterygoid muscle,passes behind the
tendon of temporal muscle through mandibular notch and
enters masseter muscle from its deep surface.
POSTERIOR AND ANTERIOR DEEP TEMPORAL NERVE:-
V Posterior temporal nerve arises from mandibular nerve close
to or together with masseteric nerve.
V Anterior temporal nerve is at its origin as a rule,united with
buccal nerve.
V the common nerve turns anteriorly and slightly laterally in a
groove on anterolateral circumference of oval foramen.
V The sulcus is bridged by a ligament,if it ossifies an abnormal
foramen is found on the base of skull and ossified ligament.
V This foramen was named temporobuccal foramen after the
old term for common trunk of anterior temporal and buccal
nerves.
V Anterior and posterior temporal nerves wind around
infratemporal crest,proceed superiorly,enters temporal
muscle from its deep or medial surface.
MEDIAL PTERYGOID NERVE:-
V It arises from the anteromedial surface of mandibular nerve.
V In most persons,it is connected with otic ganglion and passes
through it.
V Descending anteriorly,it reaches medial pterygoid muscle
close to its posterior border and not far below its origin from
pterygoid process.
V Nerve for tensor tymapni is often a branch of medial
pterygoid nerve or arises directly from mandibular nerve
close to this nerve.
V The nerve for tensor tympani arises together with medial
pterygoid nerve and passes posteriorly along the or through
the otic ganglion into canal for tensor tymapni muscle.
LATERAL PTERYGOID NERVE:-
V It usually incorporated with buccal nerve and branches off as
the buccal nerve passes b/w the two heads of lateral
pterygoid muscle and it send branches to its both heads
immediately.
V Motor fibres for anterior belley of digastric and for
mylohyoid muscle are a part of mylohyoid nerve,which is a
branch of inferior alveolar nerve.
V Four sensory branches separate from each other usually 5-10
mm below the base of skull.These branches are:-
V Buccal and lingual nerve(internal branches)
V Inferior alveolar nerve(intermediate branch)
V Auriculotemporal branch(external branch)
V It leaves the mandibular nerve at
its anterolateral surface.
V In its first part it is combined with
anterior temporal and lateral
pterygoid nerves
V First it runs anterolaterally close
to inferior surface of greater wing
of sphenoid bone and after
releasing the motor nerves it
descends behind superior head of
lateral pterygoid muscle and then
b/w two heads of muscle.
V Then after releasing fibres to
lateral pterygoid muscle it turns
sharply downward to descend on
outer surface of inferior head of
lateral pterygoid muscle,b/w
lateral pterygoid muscle and
temporalis muscle.
V At the anterior border of tendon of temporalis,it emerges and
follows the outer surface of buccinator in forward and
downward course,splits into several branches in or
underneath the outer fascia of buccinator muscle.
V Then,these branches perforate the buccinator muscle and
reach the mucous membrane of cheek.
V Almost entire mucosa of cheek is supplied by this nerve
except the posterosuperior area which may receive fibres
from posterior superior alveolar nerve.
V Area supplied by buccal nerve may extend into mucous
membrane of upper and lower lips close to corner of mouth.
V Below the foramen ovale it is
united closely to the inferior
alveoar nerve.
V Separating from inferior alveolar
nerve, usually 5-10mm
below cranial base, lingual nerve
lies anterior and slightly medial
to the inferior alveolar nerve.
V Lingual nerve descends b/w the
medial and lateral pterygoid
muscle and may be separated
from inferior alveolar nerve by
pterygospinous ligament.
V This ligament connects the
posterior border of lateral
pterygoid plate with angular
spine of sphenoid bone and it
may be partly or entirely ossified.
V If the ligament intervenes b/w
the two nerves then lingual nerve
is on medial side and inferior
alveolar on lateral side.
V At the lower border of lateral
pterygoid,lingual nerve receives
chorda tympani which carries
visceral efferent and taste fibers
from facial nerve.Below the
lateral pterygoid muscle it
courses downwards and slightly
laterally and follows the lateral
surface of medial pterygoid
muscle.
V At the level of upper end of
mylohyoid line,it turns in a sharp
curve anteriorly to continue on
superior surface of mylohyoid
muscle.
V At this point it is in close relation
to submandibular gland and
releases fibres to submandibular
ganglion.
V In most posterior part of oral cavity it is superficial and can
be seen through mucous membrane above mylohyoid line at
the level of second and third molars.
V At the same point branches are given off that supply mucous
membrane and gingiva on lingual surface of lower teeth.
V Farther anteriorly it is in close relation to sublingual gland,
which receives several fine branches,whereas other branches
supply the mucous membrane of sublingual region.
V The nerve then turns medially,spirals under submandibular
duct and divided into variable number of branches and
enters into substance of tongue.
V After exchanging fibres with the hypoglossal nerve,branches
of lingual nerve perforate muscles of tongue lateral to
genioglossus and end in mucous membrane on lower and
upper surface of body of tongue.
V At its origin it carries only fibres of general sense,that is,
touch,pressure,pain and temperature.
V Taste fibres from anterior two third of tongue derived from
facial nerve are carried to lingual nerve by chorda tympani
nerve and are distributed to the taste buds in branches of
lingual nerve.
V In mandibular third molar extraction,severe damage or
severance of the lingual nerve can result in permanent
numbness, loss of taste and dysthesia of the anterior two-
thirds of the tongue on the side of the mandibular third
molar extraction
V Parethesia, dysesthesia and anesthesia may result in the
anterior two-thirds of the tongue, floor of the mouth and
lingual gingiva.
V Of the 452 respondents, 76.05% reported having had
patients with lingual anesthesia, dysesthesia, or paresthesia.
Of all the reported cases, 18.64% of the cases failed to resolve.
Of the reported cases, only three underwent surgical
intervention.(oral surg,oral med,oral path in october 1997 by
Allen et al)
V During the impaction of third molars, the incision should
not be taken to lingual aspect of ridge as lingual nerve can
be found at or above the crest of alveolar ridge in 17% of
population.
V The normal position of lingual nerve is 2mm inferior and
0.5mm lingual to the lingual cortex.
V It is the intermediate branch of
mandibular nerve.
V It descends behind and slightly
lateral to the lingual nerve b/w
two pterygoid muscles.
V It winds around the lower border
of lateral pterygoid muscle which
separates it from ramus and then
turns sharply outwards and
downward to reach inner surface
of mandible and enters
mandibular foramen.
V Before it enters mandibular canal
it releases mylohyoid nerve which
runs in mylohyoid groove of
mandible,which is bridged by
sphenomandibular
V Sensory fibres in mylohyoid
nerve continue towards chin,
where it supplies skin on
inferior and sometimes anterior
surface of mental prominence.
V Inferior alveolar nerve passes
through mandibular canal and
divides into two unequal
terminal branches,incisive and
mental nerves.
V Mental nerve leaves the body of
mandible through mental canal
and emerges at mental foramen
and usually divides into three
branches:-
V One branch turns downwards
and forward to skin of chin.
V Other two branches course
upward and anteriorly into
lower lip,where they supply
skin and mucous membrane of
lip.
V Incisive branch is one of the dental branches of inferior
alveolar nerve.
V The dental branches vary in number and arbitrarily divides
into anterior,middle and posterior sets:-
V Posterior nerve leaves the nerve in most posterior part of the
mandibular canal.
V Middle set separates from nerve trunk below first molar or
second premolar.
V Anterior set is incisive dental nerve.

V Before dental nerves send their terminal branches,they form

inferior dental plexus.The dental nerves enter the roots of
teeth and supply pulp.
V Interdental nerves perforate the interalveolar septa, supply
the periodonatal ligaments of adjacent teeth and end in
gingival papilla.
V Inter-radicular nerves pass through intra-alveolar or inter-
radicular septa and are distributed to periodontal ligaments
of two adjascent roots.They end in PDL at bifurcation.
V There were 1,087 patients with 1,087 mandibular third molars
removed under local anesthesia from 1998 to 2003.
V Inferior alveolar nerve injury was 4.1% 1 week after surgery
and decreased to 0.7% after 2 years of follow-up, and
alteration in tongue sensation occurred in 6.5% of patients 1
week after surgery and decreased to 1.0% after 2 years of
follow-up.(Oral surg,Oral med.,Oral path in 01/11/2006
by Jerjes et al)
Î Mental nerve should be preserved in mandibular vestibular
appraoch as it comes out of the foramen b/w the root apices of
the lower premolars.
V It is the external branch of
mandibular nerve
V It separates from main trunk
below base of skull and turns
backwards and encircles
middle meningeal artery with
two branches.
V Thsese two branches unite
behind the artery and
continue posteriorly and
slightly downward and
outward to posterior surface
of mandibular neck
V After it crosses neck of
mandible and enters the
parotid gland where it gives
almost two equal branches.
V First branch bends sharply
upwards and continues in front
of cartilage of outer ear b/w
superficial artery and vein.
V On its way it sends auricular
branches back to anterosuperior
area of outer ear,external
auditory meatus,articular
branches forward to jaw joint
and other branches into parotid
gland.
V Second inferior branch split into
two or three twigs.It turns in the
substance of parotid gland
downward and laterally and
joins superior division of facial
nerve.In the sheath of facial
nerve,fibres of buccal branch of
auriculotemporal nerve
continue anteriorly and
distributed to greater posterior
part of cheek.Inferior branch is
described as Ǯanastomotic
branch of facial nerveǯ.
V This nerve should be preserved in preauricular approach for
TMJ.
V Damage is minimized by incision and dissection in close
apposition to the cartilaginous portion of the external
auditory meatus, realizing that this structure runs somewhat
anteriorly as it courses from lateral to medial.
V Temporal extension of the skin incision should be located
posteriorly so that the main distribution of the nerve is
dissected and retracted forward within the flap.
V A lesion of whole trigeminal nerve causes anesthesia of
corresponding anterior half of scalp,of the face(except
small area of face near angle of mandible supplied by
great auricular nerve),of cornea,conjuctiva,mucous
membrane of nose,mouth,and presulcal part of tongue.
V Paralysis and atrophy occur in muscles supplied by the
nerve and when the mouth is opened there is
mandibular thrust over to the paralysed side.
V Lesions of the division of nerve give more limited
sensory loss and if affecting the lingual nerve below the
point where it joins chorda tymapni,will be accompanied
by loss of taste in the corresponding half of tongue.
V Pains referred to various branches of trigeminal nerve
are of very frequent occurrence.
V As a general rule diffusion of pain over various branches
of nerve is confined to only one of main divisions,
although in several cases pain may radiate over the
branches of other main divisions.
V The commonest example is neuralgia which is so often
associated with caries.
V Here, although the tooth itself may not appear to be
painful, but these are at once relieved by treatment
directed to the affected tooth.
V In the area of ophthalmic nerve, severe supra-orbital
pain is commonly associated with acute glaucoma or
frontal or ethmoidal sinusitis.
V Malignant growths or empyema of maxillary sinus or
unhealthy condition of the inferior conchae or the septum
are often found giving rise to Maxillary neuralgia.
V In mandibular neuralgia it is quite common to meet patients
with pain in the ear,in whom there is no sign of aural disease
and the cause is found to be a carious tooth usually.

Trigger zones of trigeminal

neuralgia
V With an ulcer or cancer of tongue often first pain is
experienced which radiates to ear and temporal fossa,over
the distribution of auriculotemporal nerve.
V Lingual nerve is divided with a view to relieve pain in cancer
of tongue.
V This may be carried out where nerve lies in direct contact
with mandible below and behind the last molar
tooth,covered only by mucous membrane.
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