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Trigeminal Nerve: V3
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

Mandibular Division V3

Mandibular Division V3

Recall the area supplied with sensory innervation by the mandibular division of the trigeminal nerve (V3).

The mandibular division of the trigeminal nerve, often known simply as the mandibular nerve, contains both sensory fibres and motor fibres.

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

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition 1990. P. 60

Mandibular Division V3

Mandibular Division V3

The sensory portion of the mandibular nerve passes into the trigeminal ganglion and from there to the brainstem along with the sensory fibres from V2 and V1.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1107

The somatic motor nerve fibres leave the pons in a separate motor root, which joins the main trunk of the mandibular nerve just after it exits the cranium through foramen ovale in the greater wing of the sphenoid bone.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1107

Mandibular Division V3

Mandibular Division V3

Here it forms a common trunk for a very short distance, before giving off its first branch.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

This is a small twig containing sensory fibres, and it dives back into the cranium with the middle meningeal artery through foramen spinosum of the sphenoid bone to supply most of the dura mater with sensation. It is known as the recurrent meningeal nerve, or nervus spinosus.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

Mandibular Division V3

Mandibular Division V3

The common nerve trunk now gives off small muscular branches containing motor fibres to the tensor palati and tensor tympani muscles, and the medial pterygoid muscle.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

It also acquires small communicating branches from the otic ganglion, a parasympathetic motor ganglion which lies deep to it in the infratemporal fossa.

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

Mandibular Division V3

The nerve now divides into a larger posterior division and a smaller anterior division. A general (and inaccurate) rule: The posterior division is entirely composed of sensory branches except for one motor one. The anterior division comprises entirely motor branches except for one sensory one.

Posterior Division

Posterior Division

The branches of the posterior division of the mandibular nerve are:

Auriculotemporal nerve (sensory) Inferior dental nerve (sensory) Lingual nerve (sensory) Nerve to mylohyoid and anterior belly of digastric (motor)

Auriculotemporal Nerve

Auriculotemporal Nerve

Auriculotemporal Nerve

The auriculotemporal nerve or nerves are important because it is the sensory nerve to the TMJ and carries secretomotor fibres from the otic ganglion to the parotid gland.

It leaves the main trunk of the mandibular nerve shortly after the motor root attaches to it, and passes posteriorly towards the middle meningeal artery. It splits into two, the two branches pass around the middle meningeal artery and circle it, and then they join up again to form a single branch.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

Auriculotemporal Nerve

Auriculotemporal Nerve

It continues to run posteriorly, lying on the tensor palati muscle, and reaches the deep aspect of the neck of the mandible past which it runs, between the bone and the sphenomandibular ligament.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

It then curves around behind the temporomandibular joint which it supplies with sensory fibres and runs into the parotid salivary gland.

Modified from Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1105

Auriculotemporal Nerve

It gives off sensory and parasympathetic secretomotor fibres acquired from the otic ganglion to the gland, and then curves to run superiorly in the gland, and terminates in the superior temporal branches, which supply common sensation to the skin and underlying structures in the posterior temple area and the side of the scalp.

Inferior Dental Nerve

Inferior Dental Nerve

Inferior Dental Nerve

The inferior dental nerve, also known as the inferior alveolar nerve, is of great importance because it provides the sensory nerve supply to the pulps of the lower teeth. To do so, it must enter the body of the mandible.

It does this by passing through the mandibular foramen on the internal surface of the mandibular ramus, and running in the inferior dental canal.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Inferior Dental Nerve

J.M. Sanchis, Miguel Penarrocha, and F. Soler, Bifid Mandibular Canal. J Oral Maxillofac Surg 61:422-424, 2003
Purpose: To determine the incidence and characteristics of bifid mandibular canals. Methods: A retrospective study was performed using panoramic radiographs of 2012 patients subjected to dental treatment in the Dental Clinic of the Valencia University Dental School (Valencia, Spain) between 1996 and 1999. The goal was to investigate the presence of double mandibular canals. Results: The extraoral panoramic radiographs revealed a total of 7 images suggestive of bifid canals. Mandibular computed tomography revealed the existence of this anatomic variant in 2 of 3 patients. An analysis was performed on the incidence of this type of image in extraoral panoramic radiography, its possible interpretations, and the clinical implications of bifid mandibular canals. Conclusions: In this study, 0.35% of canals were bifid. All cases were in women.

From Shigeru Tajiri, An Atlas of Anatomy of the Head and Neck, Aproman 1998

Initially, the nerve lies in the mandibular canal as a single trunk, but soon divides into numerous smaller branches which form a plexus within the body of the mandible.

Inferior Dental Nerve

Inferior Dental Nerve

The nerve supplies the pulps of the lower teeth and their periodontal ligaments, the mandibular bone, and the labial gingivae and buccal gingivae back about as far as the second premolar.
Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 85

While in the body of the mandible, the nerve splits into two branches.

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

Inferior Dental Nerve

One of these continues forwards in the body of the mandible to supply labial gingivae and pulps of the lower anterior teeth, and it is known as the incisive nerve, or more correctly, the incisive plexus, because it has ceased to be a single nerve trunk by this stage.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101

Inferior Dental Nerve

The other exits the mandible through a small backwardsdirected foramen in the external surface of the body of the mandible called the mental foramen, usually found between the roots of the lower first and second permanent premolar teeth.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101

Inferior Dental Nerve

This branch is called the mental nerve, and it supplies common sensation to the lower lip and the front of the chin.

Nerve to the Mylohyoid

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

Nerve to the Mylohyoid

Nerve to the Mylohyoid

The nerve to the mylohyoid muscle and anterior belly of the digastric branches off from the inferior dental nerve just before it passes into the mandibular foramen. It is the only motor branch of the posterior division, which is why it supplies muscles instead of other tissues.
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Frommer and colleagues, however, showed that histologically, the mylohyoid nerve contains both sensory and motor nerve fibres.
Frommer, J, Mele, FA, & Monroe, CW. 1972. The possible role of the mylohyoid nerve in mandibular posterior tooth sensation. J. American Dental Assoc. 85, 113-117.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Nerve to the Mylohyoid

Other studies have shown that it may pass through small lingual foramina in the mandible with varying frequency in the anterior and premolar regions.
(Madeira, MC, Percinoto, C, & Silva, M. 1978. Clinical significance of supplementary innervation of the lower incisor teeth: a dissection study of the mylohyoid nerve. Oral Surg. 46: 608-614. Wilson, S, Johns, P, & Fuller, PM. 1984. The inferior and mylohyoid nerves: an anatomic study and relationship to local anaesthesia of the lower anterior teeth. J American Dental Assoc. 108: 350-352).
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Nerve to the Mylohyoid

If the nerve branches from the main trunk of V3 high enough in the infratemporal fossa to avoid being bathed in anaesthetic solution, then such patients may show signs of successful anaesthesia and still show sensitivity when dental procedures are undertaken.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Nerve to the Mylohyoid

Bennett and Townsend have shown that the mean height of the nerve branch in their series of 6 dissections was 13.4 mm with a maximum height of 20.7 mm, high enough in some cases to avoid anaesthesia with a conventional block.
(Bennett S and Townsend G. Distribution of the mylohyoid nerve: anatomical variability and clinical implications. [online]. Aust Endod J, 2001 Dec; 27 (3): 109-11).
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Nerve to the Mylohyoid

This would seem to suggest a possible accessory nerve supply for anterior and premolar mandibular teeth. Additional anaesthesia of the mylohyoid nerve can be obtained with a lingual infiltration injection in the premolar region.
(Bennett S and Townsend G. Distribution of the mylohyoid nerve: anatomical variability and clinical implications. [online]. Aust Endod J, 2001 Dec; 27 (3): 109-11).
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Nerve to the Mylohyoid

Nerve to the Mylohyoid

Indeed, Sillanpaa and colleagues anaesthetized the mylohyoid nerves of volunteer dental students and in 21% reported obtaining partial anaesthesia of the lower teeth, including the first mandibular molar.
(Sillanpaa M, Vuori V & Lehtinen R. The mylohyoid nerve and mandibular anaesthesia. Int J Oral Maxillofac Surg. 1988 Jun; 17(3): 206207).
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

A specific cutaneous sensory branch of this nerve supplying an area of the chin has recently been recognized.
(Hwang K, Han JY, Chung IH & Hwang SH. Cutaneous sensory branch of the mylohyoid nerve. J Craniofac Surg. 2005 May; 16(3): 343345 (Discussion 346)).
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Lingual Nerve

Lingual Nerve

The lingual nerve leaves the anterior aspect of the main trunk of the posterior division well above the mandibular canal, and runs parallel to the inferior dental nerve for a considerable distance. It often goes numb when the inferior dental nerve is anaesthetized.
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Lingual Nerve

Lingual Nerve

It comes to lie a little deeper than the inferior dental nerve though, and does not run into the mandible.

Netter, F. 1989, Atlas of Human Anatomy, Summit, New Jersey, CibaGeigy Medical, Plate 53.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Instead, it curves gently above the mylohyoid muscle, passing between the body of the mandible and the duct of the submandibular gland to pass beneath the duct, rising again medially to terminate in the substance of the anterior part of the tongue.

Lingual Nerve

Lingual Nerve

The lingual nerve is the major sensory nerve of the anterior two-thirds of the tongue, and therefore also carries the special sensation of taste, as well as common sensation.

It also supplies common sensation to the tissues of the floor of the mouth, and to the lingual gingival tissues. It must therefore be anaesthetized if extraction of a lower tooth is required.

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 60

Lingual Nerve

Lingual Nerve

It is commonly anaesthetized along with the inferior dental nerve during the inferior dental nerve block.

Modified from: Haglund, J. & Evers, H Local Anaesthesia in Dentistry, Astra Lkemedel Sdertlje, 2nd Edition, 1975. p. 52.

During its path as it descends towards the mylohyoid, it picks up a small branch called the chorda tympani, which carries secretomotor parasympathetic fibres which it distributes to the submandibular and sublingual salivary glands, as well as to minor salivary glands in the floor of the mouth.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101

Lingual Nerve
These are preganglionic fibres initially, and they synapse in the submandibular ganglion which is located just inferior to the lingual nerve close to the submandibular gland. The postganglionic fibres pass to the submandibular gland and some hook a ride with the continuing lingual nerve to reach the sublingual gland.
Grays Anatomy, Longmans, London, 38th Ed 1989 p. 1101

Accessory Nerve Supplies

The lingual nerve can often provide accessory innervation to anterior teeth, as can small branches from the ascending branch of the transverse cutaneous nerve of the neck. Depositing a small amount of anaesthetic lingually (with aspiration to avoid intravascular injection) will often solve the problem.

McGeachie JK. Anatomy of the lingual nerve in relation to possible damage during clinical procedures. Ann R Australas Coll Dent Surg. 2002 Oct;16:109-10.
Oral Health Centre of Western Australia. johnmcg@anhb.uwa.edu.au Damage to the lingual nerve, resulting in transient or permanent paraesthesia or anaesthesia, is a common undesirable complication of surgical interventions to the lower third molar region. The anatomy of the nerve, as it travels from its origin high in the infra-temporal fossa, to the floor of the mouth is quite variable. The most critical part of its course is where it enters the sublingual region just alongside the lingual alveolar plate of the lower third molar. A significant number of lingual nerves are located above the alveolar bone in the gingival tissues, or very close to the bone. Retraction of the lingual mucosa can lead to lingual nerve trauma. There is no doubt that the lingual nerve is extremely vulnerable in this region and clinicians must assume that it is closely adjacent to the lingual region of the lower third molar, in all cases, in order to minimize possible damage.

Anterior Division of V3

Anterior Division of V3

Buccal Nerve

The branches of the anterior division of the mandibular nerve are:

Nerves to masseter (motor) Nerves to temporalis (motor) Nerve to lateral pterygoid (motor) Nerve to medial pterygoid (motor) Buccal nerve (Sensory)

The buccal nerve, sometimes known as the long buccal nerve (especially in oral surgery), is the source of common sensation to most of the cheek and the buccal gingival tissues of the lower posterior teeth.

Modified from: Haglund, J. & Evers, H Local Anaesthesia in Dentistry, Astra Lkemedel Sdertlje, 2nd Edition, 1975. p. 53.

Buccal Nerve

Nerve Supply to Lower Teeth

It must therefore also be anaesthetized if a lower posterior tooth is to be extracted.

Modified from: Haglund, J. & Evers, H Local Anaesthesia in Dentistry, Astra Lkemedel Sdertlje, 2nd Edition, 1975. p. 53.

Pain sensation to the dental pulps of the lower teeth and common sensation to buccal and labial gingival tissues is supplied by the inferior dental nerve. Therefore, any procedure that requires anaesthesia of the pulps of any lower tooth can be performed successfully if the inferior dental nerve is blocked.

Nerve Supply to Lower Teeth

Nerve Supply to Lower Teeth

We try to anaesthetize it just before it enters the mandibular foramen, and this ensures that tooth pulps along the whole of the anaesthetized side remain numb.

Because there is some crossing over of nerve supplies from the right and left inferior dental nerves near the midline, sometimes infiltration anaesthesia is also required in this area.
Modified from: Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 87

Modified from: Haglund, J. & Evers, H Local Anaesthesia in Dentistry, Astra Lkemedel Sdertlje, 2nd Edition, 1975. p. 52.

Nerve Supply to Lower Teeth

Nerve Supply to Lower Teeth

If anaesthesia is required for extraction, however, then the nerve supply of the gingival tissues must also be considered. The lingual nerve can be blocked to ensure anaesthesia of the lingual gingivae.

Posteriorly, the buccal gingivae are supplied by the buccal nerve, and this must therefore also be anaesthetised for extractions in this region. For premolar and anterior teeth, the buccal and labial gingivae are supplied by the inferior dental nerve, and they will therefore have been successfully anaesthetised already by an inferior dental nerve block.

Accessory Nerve Supplies

Accessory Nerve Supplies

Difficulty in anaesthetizing palatal teeth is most commonly due to accessory innervation of those teeth by branches of the greater palatine nerve or from the terminal branches of the long sphenopalatine nerve. Injection of a small amount of anaesthetic palatally will normally secure anaesthesia. Other techniques such as intra-ligamental or intraosseous injections may also be useful, as may newer methods of anaesthetic delivery such as the wand.

Accessory Nerve Supplies

Accessory Nerve Supplies

Difficulty in anaesthetizing mandibular teeth is most commonly encountered in the molar area. It it recognized that the long buccal nerve, lingual nerve, mylohyoid nerve, and branches of the inferior dental nerve may all contribute to such problems. In addition, sensory fibres from the muscles of mastication may also provide an accessory innervation to these teeth. Problems due to the long buccal nerve can be overcome by administering a buccal block injection.

Accessory Nerve Supplies

Accessory Nerve Supplies

Those from the mylohyoid nerve or from accessory innervation from muscles of mastication can usually be solved by injecting into the floor of the mouth between the submandibular fold and the mandible, taking care not to inject intravascularly, especially into the facial artery. Inject through the mylohyoid muscle.

Copyright A. Forrest 2004

The cortical bone here is sometimes porous and thin enough to allow diffusion of anaesthetic into the bone to anaesthetize accessory nerve bundles from the muscles of mastication.

Accessory Nerve Supplies

Why is dental pulpal pain difficult to localize? The lingual nerve can often also provide accessory innervation to anterior teeth, as can small branches from the ascending branch of the transverse cutaneous nerve of the neck. Depositing a small amount of anaesthetic lingually (with aspiration to avoid intravascular injection) will often solve the problem. The pulp contains only pain fibres (A-delta and C fibres), therefore touch, temperature and pressure are only perceived as pain. Any potentially damaging stimulus will cause changes to the fluid in the dentinal tubules. This pain is difficult to localize unless the inflammation extends to the periodontal ligament where additional sensory receptors (pressure, proprioception) give further information.

Accessory Nerve Supplies

In addition, the numerous pain fibres of the pulp converge onto fewer fibres in the brainstem and information about the specific tooth is lost. Dental pain can be referred from one arch to the other arch, but it never crosses the midline. It may also be referred to the ear, neck etc. Dental pain may sometimes be a pain referred to the teeth from a non-odontogenic source e.g. sinuses, heart. The only way to ensure accurate diagnosis of dental pain is by thorough history taking, examination and testing.

The following resources might be useful to you: A good page on LA techniques is found at: http://www.septodont.ca/Septodont/english/other/cea_di01.html For a discussion on accessory foramina and innervation in the mandible, see: http://dmfr.birjournals.org/cgi/reprint/29/3/170.pdf For a recent American discussion of LA in Dentistry, see: http://www.cda.org/member/pubs/journal/jour0503/budenz.htm

The End