Sei sulla pagina 1di 16

COMMONWEALTH OF AUSTRALIA Copyright Regulations 1968 WARNING This material has been reproduced and communicated to you by,

or on behalf of, Griffith University, pursuant to Part VB of The Copyright Act 1968 (The Act; a copy of the Act is available at SCALEPlus, the legal information retrieval system owned by the Australian Attorney Generals Department, at http://scaleplus.law.gov.au). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of Copyright Protection under the Act. Information or excerpts from this material may be used for the purposes of private study, research, criticism or review as permitted under the Act, and may only be reproduced as permitted under the Act. Do not remove this notice.

Trigeminal Nerve: V1 and V2


Oral Biology

Alex Forrest
Associate Professor of Forensic Odontology Forensic Science Research & Innovation Centre, Griffith University Consultant Forensic Odontologist, Queensland Health Forensic and Scientific Services, 39 Kessels Rd, Coopers Plains, Queensland, Australia 4108

Learning Objectives

Learning Objectives

1. You should be able to understand and explain the gross anatomy of V in detail 2. You should be able to understand and explain the anatomy of V in both structural and functional terms, showing how these are correlated.

3. You should be able to understand and explain in detail the nerve supply of the upper and lower teeth, and the anatomical relations of the nerves involved. 4. You should understand, and be able to explain, how this information is important in local anaesthesia in the clinical setting, with particular reference to accessory nerve supplies to oral structures.

Trigeminal Nerve

Trigeminal Nerve

It is the sensory nerve of the front of the head and the face. The trigeminal nerve, or cranial nerve number five (V), is the cranial nerve of greatest importance to the dentist. It is also the motor nerve that supplies motor innervation to the muscles of mastication, the anterior belly of the digastric and the mylohyoid.

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

Trigeminal Nerve

Cutaneous Distribution

It provides sensory innervation to the oral cavity and to the dental and paradental structures. For this reason, it is branches of this nerve that are most commonly anaesthetized so that otherwise painful dental procedures can be performed comfortably for patients.

The three peripheral divisions of the trigeminal nerve supply common sensation (touch, pressure, temperature and pain) to the skin of the front of the face and the scalp as far back as the vertex of the head.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

Cutaneous Distribution

Cutaneous Distribution

The ophthalmic division (V1) supplies the skin of the anterior portion of the scalp and the forehead, the upper eyelid, and the front of the nose as far down as its tip.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

The maxillary division (V2) supplies the skin at the side of the nose, the lower eyelid and the upper part of the cheek and upper lip.

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

Cutaneous Distribution

Cutaneous Distribution

The mandibular division (V3) supplies the chin and lower lip, the skin in front of the ear, and the skin of the side of the head up to the area supplied by the ophthalmic division.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

The angle of the mandible is not supplied by the trigeminal nerve; it, along with the back of the head and much of the neck, is supplied by cervical nerves C2 and C3.

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1106

Central Connections
The unipolar somatic sensory cells of the trigeminal nerve do not have their cell bodies located in the central nervous system. Instead, they are found in the trigeminal ganglion in the same way that the cell bodies of spinal somatic sensory cells are located in the dorsal root ganglion of a spinal nerve.

Central Connections

The fibres terminate in the only nuclei for general sensation in the brainstem, the spinal nucleus and the chief sensory nucleus.

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1107

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 953

Central Connections

Central Connections

Proprioceptive fibres are important in various reflex responses involving the jaws, and because they need to be able to act very fast, these are the only peripheral sensory cells in the body whose cell bodies are located within the central nervous system. They lie in the mesencephalic nucleus.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 953

Motor cells of the trigeminal nerve originate in the trigeminal motor nucleus.

Modified from: From Grays Anatomy, Longman, London, 38th Edition, 1989. p 953.

Ophthalmic Division (V1)

The Ophthalmic Division (V1)


Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101

The ophthalmic division, or V1 as it is commonly known (for division "1" of "V", the fifth cranial nerve), is purely a sensory nerve. It contains no somatic motor fibres at all.

V1 Origins

V1 Branches

It originates in and around the orbit and forms three main branches, which pass into the cranium through the superior orbital fissure, and join up with each other to run in the lateral wall of the cavernous sinus with three other cranial nerves (III, IV and VI).

There are three major peripheral branches of this nerve, and each of those has several further branches:
Frontal Nerve Lacrimal Nerve Nasociliary Nerve

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 803

V1 Branches
The frontal nerve runs across the top of the orbit, and as it comes closer to the face, it divides into two major branches. These are the supraorbital nerve and the supratrochlear nerves. The supraorbital nerve emerges onto the face through the supraorbital foramen (sometimes this is just a notch rather than a full-blown foramen), and runs up onto the forehead to supply the tissues of the forehead and scalp.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098

V1 Branches

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098

V1 Branches
The supratrochlear nerve runs more medially and emerges from the orbit close to its medial edge. Here it runs up to supply the medial portion of the upper eyelid and the skin of the forehead and scalp towards the medial aspect of the forehead and the skin above the root of the nose.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098

V1 Branches
The lacrimal nerve supplies the conjunctiva and skin of the lateral side of the upper eyelid and the lacrimal gland with common sensation. The secretomotor nerves to the lacrimal gland are passed to the lacrimal nerve from the maxillary division of the trigeminal nerve.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098

V1 Branches

V1 Branches

In fact, they do not even originate with the trigeminal nerve, but instead with the facial nerve (VII) via the greater superficial petrosal nerve and the pterygopalatine ganglion. This is a phenomenon to which we will become used - the ability of certain groups of nerve fibres to "hitch a ride" with any passing nerve trunk that is convenient and is heading in the correct direction.

Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1100

Hence the statement that the ophthalmic nerve is purely a sensory nerve remains correct. It simply receives communication from another source, but the motor nerves do not originate with the ophthalmic nerve.

V1 Branches
The nasociliary nerve supplies the more medial structures associated with the orbit. These include the lining membranes of the sphenoidal and ethmoidal sinuses, the tissues of the roof of the nose and the skin over the front of the nose down as far as its tip.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1098

V1 Branches
You should make an effort to understand how the nerves that radiate from the orbit beneath the skin contribute to the pattern of cutaneous nerve sensation in the area supplied by V1.
Modified from: Evers H & Haegerstam G. Introduction to Dental Local Anaesthesia., Mediglobe SA, Fribourg, 2nd Ed. 1990, p. 12.

The Maxillary Division (V2)

The Maxillary Division (V2)

The maxillary division of the trigeminal nerve, often known simply as the maxillary nerve, also contains only sensory fibres.

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The Maxillary Division (V2)


The nerve originates from the trigeminal ganglion as its intermediate branch, lying between those of V1 and V3. It runs forward in the middle cranial fossa in the lateral wall of the cavernous sinus and passes out of the cranium through foramen rotundum.

The Maxillary Division (V2)

Just before it runs through the foramen, it gives off a small branch to supply the dura mater of the middle cranial fossa.

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1107

The Maxillary Division (V2)

The Maxillary Division (V2)

Once it enters foramen rotundum, it passes through the bone to emerge in the pterygopalatine fossa.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006 Illustrated Handbook in Local Anaesthesia, Ed: E. Eriksson, Munksgaard, Denmark, 1969, p.66.

When it reaches the pterygopalatine fossa, it gives off a number of branches.

The Maxillary Division (V2)

The Maxillary Division (V2)

Lying inferior to the nerve trunk is a parasympathetic ganglion called the pterygopalatine ganglion. Two branches from the nerve pass towards this, and subsequently continue through the ganglion to form further branches within the pterygopalatine fossa.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The main trunk of the nerve, however, continues anteriorly to run through the inferior orbital fissure (be sure you understand how this relates to the pterygopalatine fossa by looking at a skull), and changes its name to the infraorbital nerve.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The Maxillary Division (V2)

The Maxillary Division (V2)

It sinks down into a depressed groove in the orbital surface of the maxilla where it often gives off a middle superior dental nerve, and this groove eventually roofs over to form the infraorbital canal. The nerve runs through this canal, and eventually emerges on the facial surface of the maxilla through the infraorbital foramen.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

Here it gives of branches to the upper lip, lower eyelid and the side of the nose. In the canal, the infraorbital nerve gives off the small anterior superior dental nerve, the nerve supply to the upper anterior teeth, running in canaliculus sinosus.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The Maxillary Division (V2)

The Posterior Superior Dental Nerves

The branches of the maxillary nerve in the pterygopalatine fossa include:


posterior superior dental nerves palatine nerves sphenopalatine nerves (nasal nerves) pharyngeal nerves zygomatic nerve

The posterior superior dental nerve or nerves (there are usually several) contribute to the nerve supply of the upper teeth. They run downwards on the back of the maxilla and pass into the bone through a series of small foramina.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The Posterior Superior Dental Nerves

The Posterior Superior Dental Nerves

Here they run into the body of the maxilla, and reach the lining tissue of the maxillary sinus which they supply with sensory nerve endings. From here, the fibres are distributed further to form the molar part of the nerve plexus that supplies the upper teeth. This is known as the superior dental nerve plexus.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

Small nerve twiglets are also supplied to the gingivae on the buccal aspect of the molar teeth, and also to the superior portion of the cheek in the molar area. Because the same nerves that supply the teeth also supply the maxillary sinus lining, the pain of maxillary sinusitis is often referred to the upper teeth, especially in the premolar area.

The Palatine Nerves

The Palatine Nerves

The palatine nerves, as their names imply, provide somatic sensory nerve supply to the palate, and parasympathetic secretomotor nerves to the minor salivary glands contained in the palatal mucosa. The somatic fibres originate at first in the branches of the maxillary nerve that extend into the pterygopalatine ganglion, and emerge from this without having synapsed, because they are somatic sensory nerve fibres which do not synapse along their length.

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

While the fibres that will become the palatine nerve are in the ganglion however, some post-ganglionic parasympathetic secretomotor fibres from the ganglion get picked up and run with them to be distributed to the minor salivary glands. The nerve also contains some taste fibres.

The Palatine Nerves

The Palatine Nerves

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

Some branches of the palatine nerve emerge through the lesser palatine foramina in the palatine bones, and these are termed the lesser palatine nerves. They provide taste fibres, secretomotor fibres and common sensation to the tissues of the soft palate.

The remainder pass through the greater palatine foramen and become the greater palatine nerves, running forwards in the palate to approximately the level of the canine tooth, where they meet and anastomose with the fibres of the long sphenopalatine nerve.

The Palatine Nerves

The Sphenopalatine Nerve

Because the palatal tissues are supplied by these nerves, we need to anaesthetize them if we wish to extract a palatal tooth, because otherwise the palatal gums will remain sensitive.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

The sphenopalatine nerve passes medially into the sphenopalatine foramen, which lies in the deepest part of the pterygopalatine fossa.

The Sphenopalatine Nerve

The Sphenopalatine Nerve

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 997

After passing through the foramen, the nerve gives off some small lateral branches (short sphenopalatine nerves) which are distributed over most of the lateral wall of the nasal cavity.

The long sphenopalatine or nasopalatine nerve crosses the roof of the nasal cavity and descends on the nasal septum to supply the overlying mucous membrane.

The Sphenopalatine Nerve

The Pharyngeal Nerves

Modified from: Illustrated Handbook in Local Anaesthesia, Ed: E. Eriksson, Munksgaard, Denmark, 1969, p.66.

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1006

The nerve continues through the incisive canal to communicate with the greater palatine nerves. Small twigs help to supply the palatine supporting structures of the central and lateral incisors.

The pharyngeal nerves supply the mucous membrane of the upper nasopharynx.

The Zygomatic Nerve


The zygomatic nerve runs into the orbit through the inferior orbital fissure like the infraorbital nerve, but instead of running across the floor of the orbit, it runs on the lateral wall on the zygomatic bone, from which it takes its name. It also picks up some fibres from the pterygopalatine ganglion.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

The Zygomatic Nerve

It divides into two branches, the zygomaticotemporal nerve and the zygomaticofacial nerve which run into the zygomatic bone through two small foramina, and these emerge through foramina which take the names of the nerve branches.

The Zygomatic Nerve

The Infraorbital Nerve


The important branches of the infraorbital nerve within the orbit are the middle superior dental nerve and the anterior superior dental nerve, which contribute to the superior dental plexus.
Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

Modified from Grays Anatomy, Longmans, London, 35th Ed 1973 p. 1005

Lacrimal Branch

The parasympathetic secretomotor fibres from the pterygopalatine ganglion travel in this branch of the nerve, and they run to the lacrimal nerve of V1, travelling along it to the lacrimal gland, and constitute most of its parasympathetic secretomotor innervation.

Upper Teeth Nerve Supply

Upper Teeth Nerve Supply

As we have seen, the nerve supply to the dental pulps of the upper teeth and the nerve supply to the maxillary sinus are closely related.
http://www.septodont.ca/Septodont/english/other/cea_di01.html

The superior dental plexus is formed by twiglets from the posterior superior dental nerve, the anterior superior dental nerve, and the middle superior dental nerve when it is present.
http://www.septodont.ca/Septodont/english/other/cea_di01.html

Upper Teeth Nerve Supply

Upper Teeth Nerve Supply

When the middle superior dental nerve is present, fibres from the posterior superior dental nerve supply the molar teeth and a twig to the second premolar. The middle superior dental nerve fibres supply the mesiobuccal root of the upper first molar, the premolars, and may jointly supply the canine tooth. The anterior teeth as far back as the first premolar have twiglets from the anterior superior dental nerve.

When the middle superior dental nerve is not present, then the upper posterior teeth as far back as the second premolar are supplied with twiglets by the posterior superior dental nerve, and anterior teeth as far back as the second premolar are supplied by the anterior superior dental nerve.

Upper Teeth Nerve Supply

Upper Teeth Anaesthesia

There is no difference in the degree of sensitivity of the teeth regardless of the presence or absence of the middle superior dental nerve. The adjacent buccal gingivae are supplied by the same nerves that supply the dental pulps of the adjoining teeth.

If pulpal anaesthesia is required, for example for a filling, then anaesthesia of these nerves is all that is required. If anaesthesia is required for extraction, however, then the nerve supply of the palatal tissues must also be anaesthetized, since these will be surgically detached during the procedure.

The End

Potrebbero piacerti anche