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The mandibular nerve

The mandibular nerve is the largest branch of the trigeminal nerve, as seen in the image below. It
has mixed sensory and motor fibers (see Table 5, below).

Diagram of the third branch (mandibular) of the trigeminal nerve with

its branches.

The mandibular nerve carries sensory information from the lower lip, the lower teeth, gums, the
chin and jaw (except the angle of the mandible, which is supplied by C2-C3), parts of the
external ear, and parts of the meninges. The mandibular nerve carries touch/position and
pain/temperature sensations from the mouth. It does not carry taste sensation (the chorda tympani
is responsible for taste), but one of its branches, the lingual nerve, carries multiple types of nerve
fibers that do not originate in the mandibular nerve.

Motor branches of the trigeminal nerve are distributed in the mandibular nerve. These fibers
originate in the motor nucleus of the fifth nerve, which is located near the main trigeminal
nucleus in the pons. (See the image below.)

Diagram of the sensory and motor supply of the face.

The mandibular nerve has the following 9 branches:

 Recurrent meningeal nerve - This nerve enters the skull via the foramen spinosum with the
meningeal artery
  Medial pterygoid nerve - After passing through the otic ganglion without synapsing, this nerve
supplies the medial pterygoid, tensor veli palatini, and tensor tympani muscles
 Masseteric nerve - This nerve passes through the mandibular notch to innervate the masseter
muscle and temporomandibular joint (TMJ)
 Deep temporal nerves - The anterior and posterior branches supply the temporal muscle
 Lateral pterygoid nerve
 Buccal nerve - This nerve divides into the temporal and buccinator branches
 Auriculotemporal nerve - This nerve begins as 2 roots that encircle the middle meningeal artery,
then forms a single trunk medial to the neck of the mandible; it emerges superficially between
the ear and the mandibular condyle deep to the parotid gland and ends in 2 superficial temporal
branches (for autonomic supply to the parotid gland, see below)
 Lingual nerve - This nerve runs parallel to the inferior alveolar nerve, is joined by the chorda
tympani nerve of the facial nerve (CN VII) near the internal maxillary artery, courses forward
between the hyoglossus muscle and the deep part of the submandibular gland, and, as it passes
forward, crosses the submandibular (Wharton) duct; the lingual nerve could be injured in this
location during surgery on the floor of mouth or during excision of the submandibular gland (for
more details regarding the nerve supply of the salivary glands, see below)
 Inferior alveolar nerve - This nerve accompanies the inferior alveolar artery in the mandibular
foramen and courses into the mandibular canal to exit through the mental foramen; the
different branches are listed in Table 5, below

Table 5. Mandibular Nerve Branches and Distribution. (Open Table in a new window)

Nerve Branches Distribution

Recurrent Dura
meningeal

Medial pterygoid Medial pterygoid, tensor veli palatini, tensor

tympani muscles

Masseteric Masseter muscle, temporomandibular joint

Deep temporal Temporalis muscle

(x2)

Lateral pterygoid Lateral pterygoid muscle

Buccal • Temporal nerve (upper) Skin of cheek, mucous membrane of mouth, and
gingiva

• Buccinator nerve (lower)

Auriculotemporal • Communication with facial Parasympathetic and sympathetic supply to the
nerve, and otic ganglion, parotid gland, after relay in the otic ganglion

• Articular nerve

• Parotid gland

8) Lingual Communicates with CN VII via Taste sensations to the anterior third of tongue
chorda tympani

9) Inferior alveolar • Mylohyoid Mylohyoid, anterior, belly of digastric, molars,

premolars, canine, incisors lower lip, and chin

• Dental

• Incisive

• Mental
http://emedicine.medscape.com/article/1873373-overview#aw2aab6b2
http://www.emedicinehealth.com/trigeminal_neuralgia_facial_nerve_pain/article_em.htm

Trigeminal Neuralgia Overview

Trigeminal neuralgia causes facial pain.Trigeminal neuralgia develops in mid to late life. The
condition is the most frequently occurring of all the nerve pain disorders. The pain, which comes
and goes, feels like bursts of sharp, stabbing, electric-shocks. This pain can last from a few
seconds to a few minutes.

People with trigeminal neuralgia become plagued by intermittent severe pain that interferes with
common daily activities such as eating and sleep. They live in fear of unpredictable painful
attacks, which leads to sleep deprivation and undereating. The condition can lead to irritability,
severe anticipatory anxiety and depression, and life-threatening malnutrition. Suicidal depression
is not uncommon.

People often call trigeminal neuralgia "tic douloureux" because of a characteristic muscle spasm
that accompanies the pain.

 The pain comes from one or more branches of the trigeminal nerve-the major carrier of sensory
information from the face to the brain.

o There are 3 branches of the trigeminal nerve: the ophthalmic, maxillary, and
mandibular. The pain of trigeminal neuralgia occurs almost exclusively in the maxillary
and mandibular divisions.

o You most commonly feel pain in the maxillary nerve, which runs along your cheekbone,
most of your nose, upper lip, and upper teeth. Next most commonly affected is the
mandibular nerve, affecting your lower cheek, lower lip, and jaw.

 In almost all cases (97%), pain will be restricted to one side of your face.

 Most of the time, doctors cannot identify any disease of the trigeminal nerve or the central
nervous system.

 Trigeminal neuralgia most frequently affects women older than 50 years. The disease occurs
rarely in those younger than 30 years. Such cases are usually linked to damage from diseases of
central nervous system, for example, multiple sclerosis.

Trigeminal Neuralgia Causes

  The condition has no clear-cut cause.

o Some experts argue that the syndrome is caused by traumatic damage to the nerve as it
passes from the openings in the skull to the muscles and tissue of the face. The damage
compresses the nerve, causing the nerve cell to shed the protective and conductive
coating (demyelination).

o Others believe the cause stems from biochemical change in the nerve tissue itself.

o A more recent notion is that an abnormal blood vessel compresses the nerve as it exits
from the brain itself.
 In all cases, though, an excessive burst of nervous activity from a damaged nerve causes the
painful attacks.

Trigeminal Neuralgia Symptoms

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 A defining feature of trigeminal neuralgia is the trigger zone-a small area in the central part of
the face, usually on a cheek, nose, or lip, that, when stimulated, triggers a typical burst of pain.

o A light touch or vibration is the most effective trigger.

o Because of this, many common daily activities trigger the attacks.

 Washing your face, brushing your teeth, shaving, or talking

 Common sensations such as having wind hit your face

 Eating and chewing

 Many people avoid food and drink rather than experience the severe pain.

o These people risk weight loss and dehydration, a leading cause of hospitalization in this
group.

o People frequently require hospitalization for rapid pain control when their trigeminal
neuralgia becomes unmanageable at home.
 Between attacks, most people remain relatively pain-free. A subgroup, however, experience a
dull ache between attacks, suggesting physical compression of the affected nerve, either by a
blood vessel or some other structure.

Exams and Tests

  Your doctor must rule out a variety of other causes of facial pain besides trigeminal neuralgia,
including various unusual forms of headache.

o Atypical neuralgia

o Myofascial pain

o Temporomandibular facial pain

o Cluster headaches

o Local disease in the sinuses, jaw, throat, and bones of your head
 Physical examination of the head will help define other possible causes of this painful syndrome.
Physical findings in people with trigeminal neuralgia are normal.

 A doctor should complete an initial neurological examination to determine the presence of

other conditions, such as multiple sclerosis, that are associated with nerve pain syndromes like
trigeminal neuralgia.

 Doctors reserve more extensive testing, such as a CT scan or MRI of the head, for people in
whom they suspect an associated condition, such as skull or brain tumor, infection, or
neurological condition.

Medical Treatment

Trigeminal neuralgia is extremely painful but not life threatening. Thus, a goal of therapy is
minimizing dangerous side effects.

Medications used to treat trigeminal neuralgia are those used for many other nerve pain
syndromes-drugs originally designed to treat seizures.

These antiseizure agents suppress excessive nerve tissue activity, which is the cause of the
painful syndrome. As a result, they are useful in conditions such as trigeminal neuralgia.

Pain specialists use invasive therapy, including nerve blocks, nerve destruction, and nerve
decompression techniques, as well as drug therapy to treat trigeminal neuralgia.

 In some instances, a single injection, or a series of injections, or perhaps one decompressive

procedure, will reduce or eliminate the pain and prevent your need for a long course of drug
therapy.

 Injection techniques also can relieve unremitting pain instantly and further confirm the
diagnosis.

 Using real-time x-rays, doctors can target the anatomical origin of the nerve deep in your skull.
Then, with a fine needle, they can do one of the following to halt the painful syndrome:

o Inject that source with anesthetic and steroid.

 o Inject that nerve with a drug used to destroy faulty cells.

o This procedure can be performed with surprisingly little discomfort.

Medications

Doctors use 3 main drugs to treat trigeminal neuralgia-baclofen (Lioresal), carbamazepine

(Tegretol), and phenytoin (Dilantin).

 Baclofen is the safest of the 3, though less effective. Many doctors begin therapy with baclofen
and monitor its results over a week's time.

 For years, carbamazepine had been the mainstay for treating this disorder. In fact, many experts
believe that if you get no relief from 2 days of carbamazepine treatment, doctors must
reconsider the diagnosis of trigeminal neuralgia.

o The side effects of this drug include dizziness, sedation, confusion, and rash.

o The doctor likely will complete a series of blood and urine tests before beginning
treatment to establish a baseline of laboratory values.

o Carbamazepine in unusual instances causes a rare blood disease known as aplastic

anemia.

o Frequent blood monitoring avoids this problem. You can expect to take consistent doses
of this medicine for about 6 months before your doctor reconsiders the dosing
schedule.

Surgery

If doctors clearly determine the cause of the disorder to be compression of an artery on the
trigeminal nerve deep in your skull, a neurosurgeon can perform a microvascular decompression.

 The surgeon moves the compressing artery to a location away from the compressed root of the
nerve.

 The major disadvantage is that it requires a neurosurgical operation-with all its complications-to
get access to the root of the trigeminal nerve.