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Clinical Anatomy 27:6188 (2014)

REVIEW

Microsurgical Anatomy of the Trigeminal Nerve


WONIL JOO,1,2* FUMITAKA YOSHIOKA,2 TAKESHI FUNAKI,2 KOJI MIZOKAMI,2 AND
ALBERT L. RHOTON JR.2
1
Department of Neurosurgery, Yeouido St. Marys Hospital, The Catholic University of Korea College of
Medicine, Seoul, South Korea
2
Department of Neurosurgery, University of Florida, Gainesville, Florida

The objective of this study is to review surgical anatomy of the trigeminal


nerve. We also demonstrate some pictures involving the trigeminal nerve and
its surrounding connective and neurovascular structures. Ten adult cadaveric
heads were studied, using a magnication ranging from 33 to 403, after perfu-
sion of the arteries and veins with colored latex. The trigeminal nerve is the
largest and most complex of the cranial nerves. It serves as a major conduit of
sensory input from the face and provides motor innervation to the muscles of
mastication. Because of its size and complexity, it is essential to have thorough
knowledge of the nerve before diagnoses and treatment of the pathologic proc-
esses in the orofacial, temporomandibular, infratemporal, and pterygopalatine
areas. The trigeminal nerve is encountered with imaging or surgery of the skull
base surgery. Thus, a comprehensive knowledge of the anatomy of the trigemi-
nal nerve is crucial for performing the surgical procedures without signicant
complication. Clin. Anat. 27:6188, 2014. VC 2013 Wiley Periodicals, Inc.

Key words: trigeminal nerve (V); ophthalmic nerve (V1); maxillary nerve (V2);
mandibular nerve (V3)

INTRODUCTION ANATOMY
The trigeminal, the largest cranial nerve, is the sen- Brainstem
sory supply to the face, the major part of the scalp, the
teeth, the oral and nasal cavity, and the motor supply to The four central nuclei of the trigeminal nerve are
the masticatory and some other muscle. It also contains within the brainstem: the mesencephalic nucleus, the
proprioceptive nerve bers from the masticatory and principal sensory nucleus, the motor nucleus, and the
probably the extraocular muscle. The trigeminal nerve spinal trigeminal tract and nucleus (Figs. 1A and 1B).
has three divisions: ophthalmic, maxillary, and mandib- The mesencephalic nucleus is responsible for convey-
ular. We divide the trigeminal nerve along its course ing proprioceptive bers from the extraocular muscles
into brainstem, cisternal segment, Meckels cave seg- and masticatory muscles and modulating the bite.
ment, trigeminal ganglion, and peripheral divisions Afferent bers of the mesencephalic nucleus convey
(ophthalmic, maxillary, and mandibular divisions). pressure and kinesthesis sense from the teeth, perio-
dontium, hard palate, and temporomandibular joint
capsule. This nucleus is concerned with mechanisms
MATERIALS AND METHODS
Ten adult cadaveric heads in which the arteries and
veins were injected with colored silicone were exam- *Correspondence to: Wonil Joo, Department of Neurosurgery,
Yeouido St. Marys Hospital, The Catholic University of Korea
ined under the microscope with magnications varying College of Medicine, #62 Yeouido-dong, Yeongdeungpo-gu,
from 33 to 403. The cadaveric heads were donated Seoul 150-713, South Korea. E-mail: joowonil4858@gmail.com
to the Department of Neurosurgery at the University
of Florida by the State of Florida Anatomical Board. All Received 8 July 2013; Accepted 5 September 2013
bone work was performed with a high-speed drill Published online 9 December 2013 in Wiley Online Library
(Midas Rex Institute, Fort Worth, TX). (wileyonlinelibrary.com). DOI: 10.1002/ca.22330

C
V 2013 Wiley Periodicals, Inc.
62 Joo et al.

Fig. 1. A. Posterior schematic anatomic view and poral nerve; C., cervical; Car., carotid; Chor.Tym. N.,
superimposed diagram of the brain stem showing nuclei chorda tympani nerve;Cil., ciliary; CN., cranial nerve;
of the trigeminal nerve. The motor nucleus is situated Front., frontal; Gang., ganglion; Gen., geniculate; Gl.,
medial to the sensory nucleus of the trigeminal nerve. B. gland; GSPN., greater supercial petrosal nerve; Int.,
Sagittal schematic view passing the right trigeminal internal; Lac., lacrimal; Mesenceph., mesencephalic; N.
nuclei. C. The cutaneous innervation of the head and nerve; Nasocil., nasociliary; LSPN., lesser supercial
upper neck. There is little overlap between the three der- petrosal nerve; Nucl., nucleus; Par., parotid; Ptery. Pal.,
matomes of the trigeminal nerve. D. Parasympathetic pterygopalatine; Subling., sublingual; Submand., sub-
connections of the pterygopalatine, otic, and submandib- mandibular; Tr., tract; Trig., trigeminal; Tym. Plex., tym-
ular ganglia. The parasympathetic bers are shown as panic plexus.
purple lines. Abbreviations: Auri. Temp. N., auriculotem-

that control the force of the bite (Carpenter, 1991b). gin of the periaqeductal gray matter and anterolateral
It is located within the lower midbrain and upper pons to the fourth ventricle, medial to the sensory nucleus
lateral to the sylvian aqueduct along the lateral mar- (Figs. 1A and 1B) (Go et al., 2001).
Microsurgical Anatomy of the Trigeminal Nerve 63

The principal sensory nucleus convey impulses for stretch receptors in the muscles of mastication are
tactile and pressure sense. It is arranged in dorsoven- located in the mesencephalic nucleus in the dorsal
tral organization. Fibers of the ophthalmic division ter- pons (Dodd and Kelly, 1991). The proprioceptive
minate ventrally, bers of the maxillary division are impulses from the masticatory muscle run through the
intermediate, and bers of the mandibular division are motor root to enter the mesencephalic nucleus (Fig.
most dorsal. This nucleus lies lateral to the entering 1B) (Gray and Williams, 1989b; Shankland, 2000).
trigeminal root bers in the upper pons. Trigeminal The large sensory rootlets of the trigeminal nerve
bers from the principal sensory nucleus are both exit the lateral aspect of the midpons medial to middle
crossed and uncrossed to terminate the ventral post- cerebellar peduncle with the ophthalmic division being
eromedial (VPM) nucleus of the thalamus. Crossed most inferior, the maxillary in the middle, and the
bers originated from the ventral part of the nucleus mandibular division in the superior position (Fig. 2A).
ascend in association with the contralateral medial As the roots pass anteriorly through the prepontine
lemniscus to form ventral trigeminothalamic tract. cistern and Meckels cave to the trigeminal ganglion in
Uncrossed bers originated from the dorsomedial part the middle fossa, they rotate approximately lateral
of the nucleus ascend close to the central gray of the 180 degree rotation (Jannetta, 1996; Shankland,
midbrain to form dorsal trigeminothalamic tract (Car- 2000). However, Rhoton (2000) reported that the
penter, 1991b). bers from the mandibular division remain in a caudo-
The motor nucleus is medial to the principal sen- lateral position in the trigeminal root throughout the
sory nucleus. Fibers from this nucleus exit from the interval from the ganglion to the pons, the ophthalmic
brain stem medial to the entering sensory root, pass division rostromedial, with maxillary division bers in
underneath the trigeminal ganglion without synapse, an intermediate position (Rhoton, 2000).
and become incorporated in the mandibular division. The small motor roots emerge from the pons ante-
Axons from the mesencephalic nucleus project to the rosuperomedial to the entry point of the large sensory
motor nucleus, completing a reex arc in modulating root (Saunders and Sachs, 1970; Lang, 1981). Some
the degree of bite (Go et al., 2001). authors dened two motor rootlets groups of the tri-
The spinal trigeminal tract and nucleus relays the geminal nerve; a primary superior and a secondary
sensory modalities of pain and temperature. It extends inferior motor rootlets, with numerous connections
from the midpons to the cervical cord at the level C2- between both of these and the sensory root. The
C4 and lies anterolateral to the fourth ventricle (Bara- superior rootlets group, with its distinct position, and
kos et al., 1990; Carpenter, 1991b). Root bers enter- relative isolation from the main sensory root, repre-
ing the spinal trigeminal tract and nucleus have a sents the classic origin of the motor root (Fig. 2B)
denite topographical organization caused by medial (Saunders and Sachs, 1970; Lang, 1981; Yousry
rotation of the sensory root as it enters the pons. Fibers et al., 2004). The inferior motor rootlets are visualized
of the ophthalmic division are most ventral, bers of after retraction of the superior motor group from the
the mandibular division are most dorsal, and those of sensory root (Figs. 2B and 2C). Pelletier at al. (1974)
the maxillary division are intermediate and descend contend that the physiological characteristics of the
less far caudally than the other divisions. The spinal tri- inferior motor root were identical to that of the motor
geminal nucleus consists of three parts: (1) a pars ora- bers and subserved either a motor or proprioceptive
lis, (2) a pars interpolaris, and (3) a pars caudalis. The function rather than a sensory function (Pelletier
pars oralis receives impulses predominantly from inter- et al., 1974). The two separate motor groups join
nal structures of the nose and mouth. The pars interpo- together a short distance from the brain stem to form
laris is related mainly to cutaneous facial regions, while a single root and passes through the Meckels cave on
the pars caudalis has large receptive eld over the the medial side of the sensory root and ganglion to
forehead, cheek, and jaw. This topographic anatomy of join the mandibular division (Fig. 2C).
the spinotrigeminal pathway may explain the onion Peker et al. reported cisternal portion of the 100 tri-
peel representation of the face in the descending spino- geminal nerves measured 12.3 mm (range 815 mm).
trigeminal tract (Carpenter, 1991b; Kunc and The root exit zone (REZ) of trigeminal nerve (the pre-
Ceskoslovenska  akademie ve  d, 1964). cise nerve-pons junction) and central-peripheral mye-
lin transition zone (TZ), mentioned in the trigeminal
neuralgia, are separate structures. The length of cen-
Trigeminal Root (Cisternal Segment) tral myelin (distance from pons to TZ) on the medial
aspect of the nerve (range, 0.12.5 mm; mean, 1.13
The trigeminal nerve arises from one motor nucleus mm; median, 1 mm) was shorter than that on the lat-
and three sensory nuclei, which extend throughout eral aspect (range, 0.176.75 mm; mean, 2.47 mm;
most of the length of the brain stem. The trigeminal median, 2.12 mm) (Peker et al., 2006).
root is composed of the large sensory root and the
small motor root. The sensory root receives somato-
sensory sensation from the entire face (except the Meckels Cave Segment
angle of the jaw innervated by the cervical plexus),
temple, external acoustic meatus, and the anterior The cisternal segment of the trigeminal nerve in
scalp as far posterior as the vertex of the skull (Fig. the posterior fossa passes forward below the tentorial
1C) (Shankland, 2000). Although most cell bodies of edge and superior petrosal sinus between the perios-
the somatosensory neurons are located in the trigemi- teal and meningeal (dura propria) layers of middle
nal ganglion, the cell bodies for proprioception and fossa dura to enter Meckels cave. Meckels cave is a
64 Joo et al.

Fig. 2. A. Anterior view of the brain stem. The middle propria of the posterior fossa. The cave is situated at the tri-
cerebellar peduncle is separated from the pons by a lateral geminal impression between the meningeal layer (dura
pontine sulcus. Just lateral to the lateral pontine sulcus is propria) and the periosteal layer of dura. E. The arachnoid
the emergence of the trigeminal nerve. From the microsur- membrane from the posterior fossa extends to Meckels
gical standpoint, the apparent origin of the trigeminal nerve cave, forming a pocket within the cave, continues along the
can be considered as the limit between the pons and the rootlets of the trigeminal nerve. F. The arachnoid mem-
middle cerebellar peduncle. B. Lateral view of the right tri- brane over the trigeminal root has been removed. The
geminal root entry zone. The tentorium and the occipital superior petrosal sinus extends medially through the upper
lobe have been removed to expose the root entry zone of edge of the porus of Meckels cave and above the trigeminal
the trigeminal nerve. The small roots emerge from the pons nerve to join the cavernous sinus. Abbreviations: Ac.,
superomedial to the large sensory root. The roof of the acoustic; ACP., anterior clinoid process; AICA., anterior infe-
internal acoustic canal has been removed. C. The two motor rior cerebellar artery; Bas., basilar; Cav., cavernous; CN.,
rootlets groups of the trigeminal nerve, a primary superior cranial nerve; For., foramen; Gang., ganglion; Glossophar.,
and a secondary inferior motor rootlets, are visualized after glossopharyngeal; Inf., inferior; Int., internal; MCP., middle
superior retraction of the superior motor group from the cerebellar peduncle; Memb., membrane; Oval., ovale; Pet.,
sensory root. D. The dura of the anterior aspect of the pos- petrosal; Rotund., rotundum; Seg., segment; SOF., supe-
terior fossa has been removed to expose the basilar plexus, rior orbital ssure; Sup., superior; Tent., tentorium; Trig.,
cavernous sinus, and inferior petrosal sinus. Meckels cave trigeminal.
is a cleft-like dural pocket that originates from the dura
Fig. 3. A. The right temporal lobe has been removed The arachnoid layer has been easily removed from the pos-
to expose the middle fossa dura. B. The dura propria of the terior portion of the trigeminal ganglion due to actual subar-
middle fossa dura has peeled off to the posterior direction achnoid space. F. Superior view of the right temporal bone.
from the middle fossa oor. The trigeminal nerve has visual- The bone on the middle fossa oor has been removed later-
ized. C. Oblique coronal section along the line between the ally to show the petrous segment of the carotid artery, the
porous trigeminus and the foramen ovale (used with per- Eustachian tube, the tensor tympani muscle, and geniculate
mission from Mayeld Clinic). At the anterior margin of the ganglion of the facial nerve. The greater supercial petrosal
trigeminal ganglion, the dorsolateral and ventromedial walls nerve is separated from the horizontal segment of the pet-
of Meckels cave become an epineural sheath of each divi- rous internal carotid artery. It passes under V3 and joins the
sion of trigeminal nerve. The contents of the Meckels cave deep petrosal nerve from the sympathetic carotid plexus to
are the sensory and motor roots of the trigeminal nerve, tri- become the vidian nerve in the vidian canal. Abbreviations:
geminal ganglion, and arachnoid layer. D. The endosteal A., artery; C2., petrous carotid artery; Car., carotid; CN.,
incision near the foramen ovale leads to cleavage plane cranial nerve; Eust., Eustachian tube; Gang., ganglion;
between the outer layer (dura propria of middle fossa, Gen., geniculate; GG., gasserian ganglion; GSPN., greater
meningeal layer) and inner layer (epineural sheath of the supercial petrosal nerve; Inf., inferior; Int., internal;
mandibular nerve) (used with permission from Mayeld LSPN., lesser supercial petrosal nerve; MMA., middle
Clinic). E. The anterior portion of the trigeminal ganglion meningeal artery; N., nerve; Pet., petrosal; Sup., superior;
tightly adheres to the overlying arachnoid and dura propria Tens. Tymp.M., tensor tympani muscle; Trig., trigeminal;
of Meckels cave without any potential subarachnoid space. V3., mandibular division.
66 Joo et al.

cleft-like dural pocket that originates from the dura rior fossa into the posteromedial portion of the middle
propria of the posterior fossa, between the two layers cranial fossa (Figs. 2D2F). The superior petrosal
of the middle fossa dura, and extends from the poste- sinus extends medially through the upper edge of the

Fig. 4.
Microsurgical Anatomy of the Trigeminal Nerve 67

porus of Meckels cave and above the trigeminal nerve Kawase et al., 1996; Kehrli et al., 1997). According to
to join the cavernous sinus. The abducens nerve pier- Sabanci et al. (2011), the meningeal pouch (Meckels
ces the posterior fossa dura inferomedial to the porus cave) extended beyond the trigeminal ganglion along
trigeminus (Fig. 2D). the three divisions in some specimens, and in the
The cave is situated at the trigeminal impression others, it ended at the level of the ganglion (Sabanci
between the meningeal layer (dura propria) and the et al., 2011).
periosteal layer of dura which appears to be tightly The greater supercial petrosal nerve (GSPN) is
attached to the petrous apex (Fig. 2D). The arachnoid located posterolateral to the Meckels cave (Fig.
membrane from the posterior fossa extends to Meck- 3F). The GSPN originates at the geniculate gan-
els cave, forming a pocket within the cave, and con- glion, exits through facial hiatus, and runs under
tinues along the rootlets of the trigeminal nerve as far the dura in an anteromedial direction toward the
as the trigeminal ganglion (Figs. 2E and 2F) (Sabanci mandibular division (V3). The facial nerve hiatus
et al., 2011). The contents of the Meckels cave are was found on to be 12.8 mm posterolateral MC
the sensory and motor roots of the trigeminal nerve, (Arslan et al., 2012). The GSPN is separated from
trigeminal ganglion, and arachnoid layer (Figs. 3C and the horizontal segment of the petrous internal
3D). The anterior portion of the trigeminal ganglion carotid artery (ICA). It passes under V3 and joins
tightly adheres to the overlying arachnoid and dura the deep petrosal nerve from the sympathetic
propria of Meckels cave without any potential subar- carotid plexus to become the vidian nerve in the
achnoid space (Fig. 3E). The subarachnoid space vidian canal. The distal part of the vidian nerve will
within Meckels cave is behind the trigeminal ganglion be reviewed in the part of maxillary division.
and is actual space that constitutes the trigeminal cis- The horizontal segment of the petrous ICA is situ-
tern (Figs. 2E, 2F, 3C, and 3E) (Youssef et al., 2006). ated just below the MC. The horizontal segment
The trigeminal ganglion and trigeminal roots have two begins at the distal end of the posterior genu, courses
layers of dura propria on their superolateral aspect. anteromedially along the long axis of the petrous part
The inner layer, the dura propria, constitutes the of the temporal bone, largely below the GSPN, poste-
superolateral wall of Meckels cave. The outer layer is rior to the tensor tympani muscle and estachian tube,
the meningeal layer (dura propria) of the middle and posterior to the foramen spinosum and ovale, and
fossa. The cleavage plane is formed laterally between ends below the trigeminal nerve and ganglion at the
the epineural sheaths of the trigeminal nerves (inner anterior genu, where the artery turns upward above
layer) and dura propria of the middle fossa (outer the brocartilage-lled foramen lacerum (Fig. 3E,
layer). This cleavage plane serves as the anatomic 12A, and 12B) (Osawa et al., 2008).
basis for the interdural exposure of the contents of It is important to understand the relationships of
Meckels cave (Figs. 3A3D) (Kawase et al., 1996; the trigeminal nerve and the autonomic bers. In the
Yoshida and Kawase, 1999; Al-Mefty et al., 2002; head, there are four parasympathetic ganglia which
Youssef et al., 2006). However, the limits of the Meck- are associated with the trigeminal nerve: the ciliary,
els cave decided by its meningeal architecture remain pterygopalatine, otic, and submandibular ganglia
controversial (Taptas, 1982; Kapila et al., 1984; (Fig. 1D).

Fig. 4. A. Posterior view of the right superior orbital dle fossa, and the cavernous sinus blends into the perior-
ssure (SOF). The SOF is bounded above by the lesser bita of the orbital apex. F. Anteroinferior view of the right
wing of the sphenoid bone, below by the greater wing, orbit. The rectus muscles originate from the annular ten-
and medially by the sphenoid body. The optic strut forms don. The annular tendon surrounds the orbital end of the
the upper medial border of the ssure. The SOF provides optic foramen and the adjacent part of the SOF. The
a communication between the orbit and the middle fossa. brous component, which blend together to form the
B. Lateral view of the right cavernous sinus. The lateral annular tendon, are the periorbita covering the orbital
wall of the cavernous sinus and the anterior clinoid pro- apex, the dura lining the SOF and optic canal, and the
cess have been removed. The oculomotor, trochlear, optic sheath. G. Superior view of the right SOF. The dura
abducens, and ophthalmic division (V1) are situated covering the cavernous sinus and the optic sheath blend
within the cavernous sinus. They enter the orbit through into the periorbita of the orbital apex and into annular
the SOF. C. Superolateral view of the right fronto- tendon from which the rectus muscles arise. H. Sche-
temporal area. After performing the fronto-temporal cra- matic anterior view of the main structures passing
niotomy, the dura is elevated. The fronto-temporal dural through a right SOF. Abbreviations: A., artery; ACP., ante-
fold is located on the lateral side of the SOF, between the rior clinoid process; Cav., cavernous; CN., cranial nerve;
greater and lesser wings of the sphenoid bone. D. Resect- Div., division; For., foramen; Front., frontal; Inf., inferior;
ing the dural fold allows further detactment of the dura Lac., lacrimal; Lat., lateral; Lev., levator; M., muscle;
from the surrounding structures, enabling extradural Med., medial; N., nerve; Nasocil., nasociliary; Obl.,
exposure of the anterior portion of the cavernous sinus oblique; Oculom., oculomotor; Ophth., ophthalmic; PCP.,
and the third, fourth cranial nerves as well as the fth cra- posterior clinoid process; Rec., rectus; Rotund., rotun-
nial nerve. E. Superior view of the right orbit and the optic dum; SOF., superior orbital ssure; Sph., sphenoid; Sup.,
canal. At the SOF, the dura covering the optic nerve, mid- superior; Temp., temporal; V., vein.
68 Joo et al.

Fig. 5.
Microsurgical Anatomy of the Trigeminal Nerve 69

Ophthalmic Division At the ssure, the dura covering the middle fossa
and cavernous sinus blends into the periorbita of the
The ophthalmic nerve (V1) is the smallest of the orbital apex and into annular tendon from which the
three divisions of the trigeminal nerve. The oculomotor, rectus muscles arise (Figs. 4E and 4G). The annular
trochlear, abducens, and V1 nerves are found within tendon can be used to divide the SOF into three
the cavernous sinus. From the trigeminal ganglion, the regions: the central, lateral, and inferior sectors (Fig.
V1 is inclined upward as it passes forward in the lower 4H) (Natori and Rhoton, 1995; Shi et al., 2007). The
part of the lateral wall of the cavernous sinus to reach annular tendon surrounds the orbital end of the optic
the superior orbital ssure (Figs. 4A and 4B). The V1 canal and the adjacent part of the SOF. The central
branches into the lacrimal, frontal, and nasociliary sector of the SOF surrounded by the annular tendon
nerves as it approaches the SOF. The SOF is a small but is called the oculomotor foramen because it is the
topographically important area, which connects the part of the ssure through which the oculomotor
middle cranial fossa and the orbit (Fig. 4A) (Natori and nerve passes. The abducens and nasocillary nerves
Rhoton, 1995; Govsa et al., 1999). and branches of the carotid sympathetic plexus also
Superior orbital ssure. The superior orbital s- pass through the oculomotor foramen (Figs. 4H, 6A,
sure (SOF) is the narrow cleft through which the orbit and 6C). The nasociliary nerve is separated from
communicates with the middle cranial fossa. The SOF the oculomotor and abducens nerves by the brous
is situated between the greater and lesser wings and septum in the oculomotor foramen (Fig. 6D). The
body of the sphenoid bone. It has a somewhat trian- lateral sector is dened as lateral to the annular
gular shape, having a wide base medially on the sphe- tendon and transmits the trochlear, frontal, and lac-
noid body and a narrow apex situated laterally rimal nerve, all of which pass through the ssure
between the lesser and greater wings (Fig. 4A). At the outside the annular tendon (Figs. 4H and 5B). The
level of the SOF, the outer and inner layers of the lat- lacrimal nerve occupies the most lateral part of the
eral wall of the cavernous sinus separate from one ssure, with the frontal nerve being more medial
another (Kawase et al., 1996). The inner layer, which (Figs. 4F and 4H) (Natori and Rhoton, 1995; Shi
is composed of the cranial nerve perineurium and sur- et al., 2007). The inferior sector of the SOF is situ-
rounding connective tissue, extends with the nerves ated below the annular tendon. The inferior rectus
into the posterior orbit. The outer layer is formed by muscle arises from the annular tendon at the upper
the temporal fossa dura (Figs. 3A, 3B, and 4B). Along margin of this sector. Orbital fat extends backward
the lateral margin of the SOF, the periosteal layer of below the inferior rectus muscle into this part of the
the dura mater is contiguous with the periosteal layer ssure. This sector contains the inferior ophthalmic
of the periorbita (Froelich et al., 2007). This dural vein and orbital fat.
bridge, at the lateral edge of the SOF, is the fronto- Frontal nerve. The frontal nerve is the largest divi-
temporal periosteal fold stretched between the perior- sion of the branches of the V1. The frontal branch of
bita and temporal dural fold. The cleavage plane the V1 arises in the lateral wall of the cavernous sinus
between the temporal dura and the inner layer of the and passes through the narrow lateral part of the
lateral wall of the cavernous sinus develops after cut- superior orbital ssure on the medial side of the lacri-
ting the fronto-temporal periosteal fold (Figs. 4C and mal nerve and superior ophthalmic vein and below the
4D) (Day et al., 1994; Kawase et al., 1996). Froelich trochlear nerve. It runs forward between the levator
et al. (2007) reported that the lacrimal nerve of the palpebral muscle and the periorbita. It is visualized
V1 may be at risk during incision of periosteal fold through the periorbita after removal of the orbital roof
because it is just medial to surgical cleavage plane (Figs. 5A, 5B, and 5D). The frontal nerve courses out-
(Figs. 4F and 4H) (Froelich et al., 2007). The distance side and superolateral to the annular tendon and
between the lacrimal nerve and lateral end of the SOF divides into the supratrochlear and supraorbital nerves
was 4.21 6 1.72 mm (Shi et al., 2007). within the orbit (Fig. 5B).

Fig. 5. A. Superior view of the right orbit after muscles. D, E. Lateral view of the right SOF. The lesser
removal of the orbital roof. The periorbita has been wing of the sphenoid bone has been removed to open the
incised and retracted to expose the frontal, lacrimal, and SOF. At the level of the ssure, the nasociliary nerve
trochlear nerves. B. The orbital fat has been removed to ascends laterally to the inferior division of the oculomotor
expose the main structures of the orbit. The frontal nerve nerve and then crosses medially between the two divi-
arises in the lateral wall of the cavernous sinus and sions of the oculomotor nerve. Abbreviations: CN., cranial
passes through the narrow lateral part of the SOF on the nerve; For., foramen; Front., frontal; Gl., gland; GSPN.,
medial side of the lacrimal nerve and superior ophthalmic greater supercial petrosal nerve; Lac., lacrimal; Lat., lat-
vein and below the trochlear nerve. It runs forward eral; Lev., levator palpebral; M., muscle; MMA., middle
between the levator muscle and the periorbita. C. The meningeal artery; Nasocil., nasociliary; N., nerve; Obl.,
levator palpebral and superior rectus muscles have been oblique; Oph., ophthalmic; Ptery., pterygoid; Rec., rec-
retracted posteromedially to expose optic, nasociliary, tus; Rotund., rotundum; SOF., superior orbital ssure;
and abducens nerves. The nasociliary nerve passes for- Sup., superior; Suporb. N., supraorbital nerve; Sup.-
ward above the optic nerve to reach the medial part of the Troch. N., supratrochlear nerve.
orbit between the superior oblique and medial rectus
70 Joo et al.

Supratrochlear nerve. The supratrochlear nerve runs 5C). The nerve gives off a descending lament to the
anteriorly above the trochlea of the superior oblique infratochlear branch of the nasociliary nerve. The
muscle with the supratochlear artery (Figs. 5B and supratrochlear nerve exited between the trochlea and

Fig. 6.
Microsurgical Anatomy of the Trigeminal Nerve 71

the supraorbital foramen and was located 16 mm lat- crosses medially between the two divisions of the ocu-
eral to the midline (range, 12-21 mm) and 7 mm lomotor nerve and above the optic nerve to reach the
below the upper margin of the supraorbital rim medial part of the orbit, where it gives rise to the
(range, 6-9 mm) (Jeong et al., 2010). The supratro- anterior and posterior ethmoidal and infratrochlear
chlear nerve is located medial to the supraorbital nerves (Figs. 5C and 5E).
nerve at the supraorbital rim (Cuzalina and Holmes, The nasociliary nerve connects with the ciliary gan-
2005). It supplies the conjunctiva and the skin of the glion and gives off the long ciliary nerves. The sensory
upper eyelid and ascends beneath the corrugator and root of the ciliary ganglion arises from the nasociliary
the frontal belly of occipitofrontalis, dividing into nerve. This sensory root courses forward on the lat-
branches which pierce these muscles to supply the eral side of the optic nerve and enters the ciliary gan-
skin of the lower forehead near the midline (Gray and glion but does not synapse with any cell bodies.
Williams, 1989b). Several ne laments known as the short ciliary
Supraorbital nerve. The supraorbital nerve courses nerves leave the ciliary ganglion and convey sensation
between the levator palpebrae muscle and orbital roof. to cornea and globe. The long ciliary nerves accom-
The supraorbital nerve exited the supraorbital notch or pany the short ciliary nerves to pierce the sclera near
foramen 29 mm lateral to the midline (2533 mm) and the attachment of the optic nerve. The long ciliary
5 mm below the upper margin of the supraorbital rim nerves convey sympathetic bers to the globe and
(range, 46 mm) (Jeong et al., 2010). The nerve inner- pupillary dilator and may also carry some sensation
vates the upper eyelid, the mucous membrane of the from the globe and cornea (Figs. 6B, 6E, and 6F)
frontal sinus of the frontal bone, the galea aponeurosis, (Rhoton, 2003b; Shankland, 2001a).
and the orbicularis oculi. It ascends on the forehead, Lacrimal nerve. The lacrimal nerve is the smallest
dividing into a smaller medial and a lateral branch, of the three division of the V1. It arises at the level of
which supply the skin of the scalp nearly as far back as or just behind the SOF from the lateral edge of the V1
the lambdoid suture (Gray and Williams, 1989b; and passes through the lateral edge of the ssure on
Shankland, 2001a). It may also carry some sympa- the lateral side of the frontal nerve and above the
thetic bers to the globe and pupillary dilator (Rhoton, superior ophthalmic vein (Figs. 4H and 5A5C). On
2003b). The supraorbital nerve may transmit auto- entering the orbit, the lacrimal nerve courses along
nomic bers from the cervical sympathetic ganglia to the superior margin of the lateral rectus muscle and
the lobe and pupillary dilator (Martins et al., 2011). serve as a bridge to parasympathetic twigs directed to
Nasociliary nerve. The nasociliary nerve, interme- the lacrimal gland (Figs. 6C and 6F). These twigs are
diate in size between the frontal and lacrimal nerves, related to the pterygopalatine ganglion (PPG). The
is more deeply placed in the orbit. The nasociliary postganglionic parasympathetic motor bers contain-
nerve arises from the medial side of the V1 and is sit- ing lacrimal secretomotor bers, carried by the zygo-
uated above and lateral to the abducens nerve in the matic branch of the maxillary division, which course
anterior part of the cavernous sinus (Figs. 5C5E). along the lateral orbital wall, join the lacrimal nerve
Both the abducens and the nasociliary nerves course (Fig. 1D) (Shankland, 2001a; Rhoton, 2003b; Martins
medial to the part of the V1 from which the lacrimal et al., 2011). The lacrimal nerve also conveys sensa-
and frontal nerves arise. At the level of the ssure, tion from the area in front of the lacrimal gland.
the nasociliary nerve gently ascends laterally to the Ciliary ganglion. The ciliary ganglion is located at
inferior division of the oculomotor nerve and then the inferolateral aspect of the optic nerve and at the

Fig. 6. A. Lateral view of the right SOF. The lesser don has been divided between the origin of the superior
wing of sphenoid bone and lateral wall orbit have been and lateral rectus muscles. The nasociliary nerve sepa-
removed to expose the structures passing through the rates from the oculomotor and abducens nerves by
SOF. The frontal nerve has been retracted inferolaterally. brous septum within the oculomotor foramen. E. The
The lateral sector transmits the trochlear, frontal, and lac- levator and superior rectus muscles have been reected
rimal nerves, all of which pass through the ssure outside medially and lateral rectus muscle has been reected lat-
the annular tendon. B. Superior view of the right orbial erally to expose the right optic nerve (removed) and short
apex. The optic nerve has been retracted medially to ciliary nerve arising from the ciliary ganglion. F. Anterior
expose the ciliary ganglion. The ciliary ganglion receives view of the right orbit and extraocular muscles after
parasympathetic motor root from the inferior oculomotor removing the eye globe and optic nerve. The lacrimal
nerve, sensory root from the nasociliary nerve, and sym- nerve courses along the superior margin of the lateral
pathetic bers from the plexus around ophthalmic artery. rectus muscle. The nasociliary nerve gives rise to long cil-
C. Enlarged view of the SOF. The lateral margin of the SOF iary nerves that enter the sclera around the optic nerve
in (A) has been removed. The oculomotor foramen is the with the short ciliary nerves arising from the ciliary gan-
portion of the opening in the annular tendon lateral to the glion. Abbreviations: A., artery; Cil., ciliary; CN., cranial
optic foramen through which the superior and inferior nerve; Div., division; Front., frontal; Gang., ganglion; Inf.,
divisions of the oculomotor nerve and the nasociliary inferior; Lac., lacrimal; Lat., lateral; M., muscle; N.,
nerve and abducens nerve pass. The nasociliary nerve is nerve; Nasocil., nasociliary; Obl., oblique; Ophth., oph-
situated above and lateral to the abducens nerve in the thalmic; Rec., rectus; SOF., superior orbital ssure; Sup.,
anterior part of the cavernous sinus. D. the annular ten- superior; Sympath., sympathetic.
Fig. 7. A. Anterior view of the sphenoid bone. The oblique line in the mandible runs upward and backward
anterior opening of the vidian canal is situated inferome- from the mental tubercle and is continuous with the ante-
dial to the foramen rotundum. B. Posterior view of the rior border of the ramus. The upper border of the ramus is
sphenoid bone. The pterygoid processes of the sphenoid thin and bounds a wide notch, the mandibular incisures,
descend perpendicularly from the region where the which transmits the masseteric nerve and vessels from
greater wings unite with the body. Each process consists the infratemporal fossa. F. Posterior view of the mandible.
of the medial and a lateral plate, the upper parts of which The mandibular canal runs from the mandibular foramen
are fused anteriorly. The medial pterygoid plate is nar- obliquely downward and forward in the ramus and then
rower and longer than the lateral; its lower end curves lat- horizontally forward in the body. The mylohyoid line is the
erally into a hook-like process, the pterygoid hamulus, origin of the mylohyoid muscle. The lingula, the medial
around which the tendon of the tensor veli palatini is border of the mandibular foramen, is the attachment site
deected. C. Lateral view of the infratemporal fossa. The of the sphenomandibular ligament. Abbreviations: Alve.,
pyramidal process of the palatine bone ts into the angu- alveolar; Art., articular; Car., carotid; Condy., condyle;
lar interval between the lower ends of the pterygoid Fiss., ssure; For., foramen; Inf., inferior; Infratemp.,
plates. The medial portion of the tympanic part of the infratemporal; IOF., inferior orbital ssure; Lac., Lac-
temporal bone forms the posterior boundary of the petro- erum; Lat., lateral; Mand., mandible; Med., medial; Obl.,
tympanic ssure. D. Inferior view of the infratemporal oblique; Palatomax., palatomaxillary; Ptery., pterygoid;
fossa. The sulcus for auditory tube, which is the attach- Pterygomax., pterygomaxillary; Petrotym., petrotym-
ment site of the cartilaginous part of the Eustachian tube panic; Pyra. Proc., pyramidal process; Scaph., scaphoid;
to the cranial base, is located on the extracranial surface SOF., superior orbital ssure; Sph., sphenoid; Spin., spi-
of the spenopetrosal ssure, anterolateral to the foramen nosum; Squam., squamous; Stylo., styloid; Submand.,
lacerum and posteromedial to the foramen ovale and spi- submandibular; Sul., sulcus; Temp., temporal; Tym.,
nosum. The foramen ovale, which is irregularly oval, lies tympanic. [Color gure can be viewed in the online issue,
close to the upper end of the posterior margin of the lat- which is available at wileyonlinelibrary.com.]
eral pterygoid plate. E. Lateral view of the mandible. The
Microsurgical Anatomy of the Trigeminal Nerve 73

medial side of the lateral rectus muscle. The ganglion is region of the foramen rotundum and lateral aspect of
an oval-shaped collection of cell bodies about 3 mm in the V2. The venous vascularization of this area may
size (Figs. 6B, 6E, and 6F). The mean distance between cause a bleeding in surgical intervention of the middle
the ganglion and the optic nerve was 2.9 mm (range, cranial fossa (Figs. 8A and 8B) (Simoes, 1993; Tubbs
2.73.1 mm) and the mean distance between the lat- et al., 2008).
eral rectus muscle and the ganglion was 10.4 mm The maxillary nerve passes through the foramen
(range:9.211.2 mm) (Izci and Gonul, 2006). It rotundum to enter the pterygopalatine fossa (PPF),
receives three branches: parasympathetic motor root where it becomes more cylindrical and compact. The
from the branch of the inferior oculomotor division to PPF is pyramidal space located between the pterygoid
the inferior oblique muscle, sensory root from the naso- bone posteriorly, the perpendicular plate of the pala-
ciliary nerve, and sympathetic bers from the plexus tine bone anteromedially, and maxilla anterolaterally.
around the ophthalmic artery (Figs. 1D, 6B, 6E, and 6F). It opens laterally into the medial part of the infratem-
The parasympathetic bers, originated in the poral fossa through the pterygomaxillary ssure and
Edinger-Westphal nucleus of the oculomotor complex superiorly through the medial part of the inferior
in the midbrain, synapse in the ciliary ganglion, which orbital ssure into the orbital apex (Figs. 7C and 7D).
gives rise to the short ciliary nerves. These bers sup- The fossa also communicates with middle cranial
ply the ciliary muscle and the sphincter of the pupil. fossa posterolaterally through the foramen rotundum,
The sympathetic bers ascend on the surface of the with foramen lacerum posteromedially through the
internal carotid artery, pass through the central sector vidian canal, with the naospharynx medially through
of the SOF, and course with the ophthalmic artery. the palatovaginal canal, with the oral cavity inferome-
The sympathetic bers, which relay in the superior dially through the palatine foramina, and with nasal
cervical ganglion, traverse the ciliary ganglion without cavity medially through the sphenopalatine foramen
synapse and enter the short ciliary ganglion. The sen- (Figs. 7A, 7B, and 8D) (Aleri et al., 2003). It contains
sory root from the nasociliary nerve passes to the maxillary nerve, PPG, maxillary artery, and their
globe through the short ciliary nerves and convey sen- branches, all embedded in fat tissue. The anterior
sation to cornea and globe (Fig. 6B). compartment of the PPF contains the third segment of
the internal maxillary artery and its branches (Morton
Maxillary Division and Khan, 1991). The posterior compartment of the
PPF contains the PPG and its branches the maxillary
The maxillary nerve (V2), the intermediate division nerve (V2) (Figs. 8C8E, and 8F) (Aleri et al., 2003).
of the trigeminal nerve, is purely sensory in function. The V2, after entering the PPF, gives off ganglionic
The V2 gives sensory innervation to all structures in branches to the PPG. It then deviates laterally just
and around the maxillary bone and the mid-facial beneath the inferior orbital ssure, giving rise to zygo-
region including the skin of the mid-facial regions, the matic and posterosuperior alveolar nerves outside of
lower eyelid, side of the nose and upper lip; the the periorbita. The V2 then turns medially as the infra-
mucous membrane of the nasopharynx, maxillary orbital nerve, passing through the inferior orbital s-
sinus, soft palate, palatine tonsil, roof of the mouth, sure to enter the infraorbital groove, where the
the maxillary gingiva, and maxillary teeth (Fig. 1C) anterior and middle superior alveolar nerves arise
(Shankland, 2001b). (Figs. 8B, 8D, 8E, and 8F).
Conicting statements exist in the literatures The branches of the V2 can be divided into four
regarding the presence or absence of V2 within the groups corresponding to their origins, as follows: in
cavernous sinus. In many classic textbooks, oculomo- the cranium, the pterygopalatine fossa, the infraor-
tor, trochlear, V1, and V2 are described as being bital canal, and on the face.
embedded in the lateral wall of the cavernous sinus In the cranium.
(Hollinshead, 1982a; Dolenc, 1989; Gray and Wil- Meningeal nerve. The meningeal nerve arises from
liams, 1989a; Fix, 1995). However, some authors the V2 within the middle cranial fossa near the fora-
have stated that V1 is the only part of the trigeminal men rotundum. It receives a ramus from the internal
nerve to reside in the cavernous sinus (Carpenter, carotid sympathetic plexus and accompanies the fron-
1991a; Rhoton, 2003a; Tubbs et al., 2008). The V2 tal branch of the middle meningeal artery to supply
leaves the middle portion of the trigeminal ganglion the dura mater in the middle cranial fossa. Its anterior
between ophthalmic (V1) and mandibular (V3) divi- small branches just reach the anterior cranial fossa.
sions. The V2 does not course in the lateral wall of the This is the smallest branch of the V2 (Gray and Wil-
dural envelop of the cavernous sinus as does the oph- liams, 1989b; Shankland, 2001b).
thalmic nerve (Figs. 4B and 8B). It courses beneath In the pterygopalatine fossa.
the dura of the middle fossa below the level where the Ganglionic branches. The ganglionic branches in
medial and lateral walls of the cavernous sinus join at the pterygopalatine fossa (PPF) connect the V2 to the
the lower edge of the ophthalmic nerve. As the dura is PPG. The pterygopalatine ganglion (PPG) is located
elevated from the oor of the middle fossa, it can be inferior and medial to the maxillary nerve (V2) (Figs.
stripped upward off the lateral aspects of both the V1 8C8F). The ganglionic branches contain postgan-
and V2 nerves, but only the ophthalmic nerve has the glionic parasympathetic nerve bers to the lacrimal
venous space of the cavernous sinus on its medial gland, which join the V2 and pass into its zygomatico-
side (Fig. 4D) (Rhoton, 2003a). The laterotrigeminal temporal nerve, and reach the lacrimal gland via the
venous system, which is the venous system surround- communication between the zygomaticotemporal
ing the foramen ovale and V3, may be extend to the nerve and lacrimal nerve (Fig. 1D). They also contain
74 Joo et al.

sensory bers from the orbital periosteum and the Zygomatic nerve. The zygomatic nerve arises from
mucosa of the nose, palate, and pharynx (Gray and the V2 in the PPF, passes anteriorly, superiorly, and
Williams, 1989b). laterally to enter the orbit through the inferior orbital

Fig. 8.
Microsurgical Anatomy of the Trigeminal Nerve 75

ssure. It runs along the lateral wall of the orbit and matic region can vary from one to three (Moretto
divides into zygomaticotemporal and zygomaticofacial et al., 2005). The posterior superior alveolar nerves
nerves (Fig. 8B and 9C). communicate with the middle superior alveolar nerve
Zygomaticotemporal nerve. The zygomaticotempo- and give branches which form a dental plexus (Shank-
ral nerve passes along the inferolateral angle of the land, 2001b). It also supplies a branch to the upper
orbit, gives off the communicating branch to the lacri- gum and the adjoining part of the cheek (Gray and
mal nerve of the V1, traverses a bony canal in the Williams, 1989b).
zygomatic bone, and enters into the temporal fossa. Pterygopalatine ganglion. The pterygopalatine
It then ascends between the bone and the temporalis ganglion (PPG), the largest of the peripheral parasym-
muscle and pierces the deep temporal fascia approxi- pathetic ganglia, is located deeply in the PPF, near the
mately 2 cm above the zygomatic arch to innervate sphenopalatine foramen and anterior to pterygoid
the skin of the temporal area (Totonchi et al., 2005). canal, and associated with the V2. The ganglion
Sometimes, when the lacrimal nerve is lacking, the receives communicating rami from the V2 (ganglionic
zygomaticotemporal nerve becomes its replacement branches) superolaterally and vidian nerve superome-
and innervates the lacrimal gland (Shankland, dially and gives rise to the greater and lesser palatine
2001b). nerves from the lower surface of the ganglion, sphe-
Zygomaticofacial nerve. The zygomaticofacial nerve nopalatine nerve, and pharyngeal branch from the
also courses the inferolateral angle of the orbit, medial surface and the orbital branch from the supe-
emerging on the face through a zygomaticofacial fora- rior surface (Figs. 8C8F, 9A, and 9B). The vidian
men in the zygomatic bone, and supplies the skin on nerve is formed by the union of the greater petrosal
the prominence of the cheek. It forms a plexus with nerve, which conveys parasympathetic bers arising
zygomatic branches of the facial nerve and palpebral from the facial nerve (nerve intermedius) at the level
branches of the V2. of the geniculate ganglion, and deep petrosal nerve,
Posterior superior alveolar nerves. The poste- which conveys sympathetic bers from the carotid
rior superior alveolar nerve arises from the maxillary plexus, to reach the lacrimal gland and nasal mucosa
nerve before penetrating into the infraorbital canal in (Figs. 1D, 8G, and 9A).
the PPF and descends anteriorly and inferiorly to Palatine nerves. The palatine nerves are distrib-
pierce the infratemporal surface of the maxillary sinus uted to the roof of the mouth, the soft palate, tonsil,
(Figs. 8C and 8F). After entering the maxillary sinus, and the nasal mucosa. They also convey taste
the nerves pass forward under the mucosa of the impulses from the palate via the PPG and vidian nerve
maxillary sinus, supplying afferent innervation to to the nervus intermedius of the facial nerve, which
these membranes. The number of posterior superior terminates to the solitary tract and nucleus of the
alveolar nerves that originate from the V2 in the zygo- brain stem (Fig. 1D). The greater palatine nerve

Fig. 8. A. Superior view of the middle fossa. The mid- removed to expose the pterygopalatine fossa and gan-
dle fossa dura has been removed to expose the trigeminal glion. The maxillary arteries enter the pterygopalatine
nerve. The laterotrigeminal venous system is the venous fossa from the laterally by passing through the pterygo-
system surrounding the foramen ovale and mandibular maxillary ssure and give rise to its terminal branches in
division. B. Superolateral view of the right trigeminal the pterygopalatine fossa. F. Lateral view of the right
nerve. The bone surrounding the foramen rotundum and pterygopalatine fossa. The maxillary nerve is situated
ovale has been removed to expose the maxillary and superior and lateral to the pterygopalatine ganglion. The
mandibular divisions, respectively. Removing bone in the vidian nerve, which courses the oor of the sphenoid
triangular space between the ophthalmic and maxillary sinus, is inferomedial to the maxillary nerve and joins the
nerve opens into the sphenoid sinus. The maxillary nerve pterygopalatine ganglion. The maxillary nerve also gives
enters the pterygopalatine fossa by passing through the rise to the zygomatic and the posterior superior alveolar
foramen rotundum. C. Lateral view of the right pterygo- nerves. G. The trigeminal nerve has been reected later-
palatine fossa. The temporal bone, mandibular ramus, ally to expose the vidian nerve. The vidian nerve is
and pterygoid muscles have been removed to expose the formed by the union of the GSPN and deep petrosal nerve.
branches of the maxillary nerve in the pterygopalatine H. Coronal section through the orbital apex behind the
fossa. The vascular structures are anterior to nervous pterygopalatine fossa. The anerior end of vidian canal,
structures in the pterygopalatine fossa. D. Inferior view which opens into the medial part of the posterior wall of
of the pterygopalatine fossa. The pterygopalatine gan- the pterygopalatine fossa, is funnel shaped. Abbrevia-
glion is located inferior and medial to the maxillary nerve. tions: A., artery; Alv., alveolar; Br., Branch; Car., carotid;
The ganglionic branch in the pterygopalatine fossa con- CN., cranial nerve; Eth., ethmoid; For., foramen; Gang.,
nects between the maxillary nerve and pterygopalatine ganglion; GSPN., greater supercial petrosal nerve; Inf.,
ganglion. After crossing the upper part of the pterygopa- inferior; Infraorb., infraorbital; Int., internal; IOF., inferior
latine fossa, the maxillary nerve inclines laterally and orbital ssure; Lat., lateral; M., muscle; Max., maxillary;
then enters the infraorbital groove and canal. E. Cross N., nerve; Pet., petrosal; Pit., pituitary; Post., posterior;
section through the ethmoidal and maxillary sinuses and Proc., process; Ptery., pterygoid; pterygopal., pterygopa-
the nasal cavity in front of the posterior maxillary wall. latine; Rotund., rotundum; Seg., segment; Sph., sphe-
The posterior wall of the maxillary sinus has been noid; Sup., superior; Sympath., sympathetic.
76 Joo et al.

Fig. 9.
Microsurgical Anatomy of the Trigeminal Nerve 77

descends through the greater palatine foramen of the the nervus intermedius. The postganglionic parasym-
maxilla located at the inferior tip of the PPF and runs pathetic bers pass through the V2 and its zygomatic
forward in a groove on the inferior surface of the hard branch to enter orbit through the inferior orbital s-
palate (Figs. 9A and 9E). It communicates with the l- sure and reach the lacrimal gland through a communi-
aments of the nasopalatine nerve, a branch of the cation with the lacrimal branch of the ophthalmic
sphenopalatine nerve. The thickest nerves connecting nerve (Fig. 1D) (Gray and Williams, 1989b; Rhoton,
the PPG were invariably the sphenopalatine nerve and 2003b; Rahman et al., 2009). The deep petrosal
greater palatine nerve (Rusu et al., 2009). nerve contains postganglionic sympathetic bers that
The lesser palatine nerves, after leaving the PPG, arise in the superior cervical ganglion and travel
descend through a lesser palatine foramen in the pal- upward in the nerve plexus on the internal carotid
atine bone and give branches to the uvula, tonsil, and artery. Therefore, the vidian nerve contains sensory,
soft palate. These nerves anastomose with branches sympathetic, and parasympathetic bers. The para-
of the glossopharyngeal nerve to form a tonsillar sympathetic bers synapse in the PPG, however, the
plexus around the palatine tonsil (Fig. 9E) (Shankland, sensory and the sympathetic bers pass through the
2001b). ganglion without synapse (Gray and Williams, 1989b;
Vidian nerve. The vidian canal connects the PPF el Shazly, 1991; Rahman et al., 2009).
and the foramen lacerum. It conveys the vidian nerve, The vidian canal and nerve have become important
artery, and vein and contains adipose tissue. The landmarks in directing the microsurgical and endo-
anterior opening of the vidian canal is located infero- scopic approaches along the oor of the sphenoid
medial to the foramen rotundum in the posterior wall sinus to the petrous carotid and the anteromedial part
of the PPF (Fig. 8D). The canal is a straight to slightly of the cavernous sinus and Meckels cave (Figs. 8G
curved pathway directed posterolaterally from its and 9B) (Rahman et al., 2009).
anterior opening (Figs. 8D and 8H) (Kim et al., 1996). Nasal branches. The nasal branches enter the
The canal sits just below the oor of the well- nasal cavity through the sphenopalatine foramen in
pneumatized sphenoid sinus (Figs. 8D and 8F). The the lateral wall of the nasal cavity. These branches
posterior opening is located above the posterior edge include medial and lateral posterior superior nasal
of the medial pterygoid plate. It opens posteriorly into nerves and nasopalatine nerves (Fig. 9B).
the upper part of the anterolateral edge to the fora- Lateral posterior superior nasal nerves. The lateral
men lacerum (Fig. 8D). The posterior opening of the posterior superior nasal branches, usually six in num-
vidian canal is situated 6.9 mm (range, 4.89.1 mm) ber, innervate the mucosa of the posterior part of the
medial to the medial edge of the foramen ovale and superior and middle nasal conchae and the lining of
V3 (Rahman et al., 2009). the posterior ethmoidal sinuses (Gray and Williams,
Although the vidian nerve, formed by the union of 1989b).
the greater and deep petrosal nerves, is not the Medial posterior superior nasal nerves. The medial
branch of the V2, it enters and passes through the posterior superior nasal branches, usually two to three
vidian canal and ends in the PPG, which is positioned in number, cross the nasal roof below the opening of
in front to the anterior opening of the vidian canal the sphenoidal sinus to supply the mucosa of the pos-
(Fig. 8G). The greater petrosal nerve (GSPN) contains terior part of the roof and of the nasal septum (Gray
taste bers from the palatal mucosa and preganglionic and Williams, 1989b).
parasympathetic bers that arise from the superior Nasopalatine nerve. The nasopalatine nerve, the
salivary nucleus in the brainstem and are conveyed in largest nerve of the nasal branches of the PPG, travels

Fig. 9. A. Enlarged anterior oblique view of the ptery- located anterior to the pterygopalatine ganglion. The pal-
gopalatine fossa. The pterygopalatine ganglion receives atine nerves descend through the palatine foramina of
communicating rami from the maxillary nerve. The sphe- the maxilla located at the inferior tip of the pterygopala-
nopalatine branch passes through the sphenopalatine tine fossa. F. The right buccolabial muscles have been
foramen to enter the lateral nasal cavity. B. The terminal removed to expose the branches of the infraorbital nerve.
branch of the maxillary artery and nasal branches arising The branches of the infraorbital nerve communicate with
from the pterygopalatine ganglion penetrate the lateral the branches of the facial nerve to form infraorbital plexus
wall of the nasal cavity to course along the sphenoid face. in the infraorbital space. G. The branches of the infraor-
C. Anterosuperior view of the orbit. The maxillary nerve bital nerve have been removed. The infraorbital nerve
gives rise to the infraorbital, zygomatic, and superior gives rise to anterior superior alveolar nerve just behind
alveolar nerves. The anterior wall of the pterygopalatine the infraorbital exit through the foramen. Abbreviations:
fossa is formed by the posterior wall of the maxillary A., artery; Alv., alveolar; Ant., anterior; Br., branch; CN.,
sinus. D. Anterosuperior view of the maxilla. The maxil- cranial nerve; For., foramen; Gr., great; Inf., inferior;
lary nerve enters the infraorbital groove and canal by Infraorb., infraorbital; Max., maxillary; N., nerve; Pit.,
passing through the inferior orbital ssure and continues pituitary; Post., posterior; Pterygopal., pterygopalatine;
as the infraorbital nerve. The infraorbital nerve emerges Rotund., rotundum; SOF., superior orbital ssure; Sph.,
in the face through the infraorbital foramen. E. The poste- sphenoid; Sphenopal., sphenopalatine; Sup., superior;
rior wall of the right maxillary sinus has been removed to Temp., temporal; Zygo., zygomatic.
expose the pterygopalatine fossa. The maxillary artery is
78 Joo et al.

through the sphenopalatine foramen to enter the located within 1 cm of the inferior border of the orbital
nasal cavity just below the orice to the sphenoid rim, the ION divides into the inferior palpebral, inter-
sinus to reach the nasal septum. It then runs ante- nal and external nasal, and superior labial branches,
roinferiorly between the periosteum and mucous which supply skin and conjunctiva of the inferior eye-
membrane of the nasal septum, supplies a few la- lid, lateral part of the nose, and the skin and mucosa
ments to the nasal septum, exits the nasal cavity of the upper lip (Figs. 9D and 9F) (Gray and Williams,
through the incisive foramen, and ends by supplying 1989b; Moore and Dalley, 1999; Hu et al., 2006).
the mucosa of the anterior part of the hard palate, When the ION emerges from the infraorbital fora-
there communicating with the greater palatine nerves men, three branches except for the inferior palpebral
(Gray and Williams, 1989b; Shankland, 2001b). branch run downward. The infraorbital space is placed
Pharyngeal nerve. The pharyngeal nerve arises inferior to the infraorbital foramen and here the ION
from the posterior part of the PPG, traverses the pala- that travels downward and the facial nerve that trav-
tovaginal canal with a pharyngeal branch of the maxil- els transversely form the infraorbital plexus (Fig. 9F)
lary artery, and supplies the mucosa of the (Hu et al., 2006).
nasopharynx behind the auditory tube. The palatova- Inferior palpebral branches. The inferior palpe-
ginal canal is a short bone tunnel formed by the appli- bral branches, usually two or three in number, ascend
cation of the sphenoid process of the palatine bone to deep into the orbicularis oculi muscle, piercing the
the vaginal process of the sphenoid bone (Figs. 7B muscle to supply the skin and conjunctiva of the lower
and 11B) (Wentges, 1975). The palatovaginal canal is eyelid. These nerves communicate with the facial and
located medial and inferior to the vidian canal. The zygomaticofacial nerves near the lateral canthus (Fig.
palatovaginal canal is found inferomedially on the pos- 9F).
terior wall of the PPF, in the roof of the nasopharynx. Nasal branches. The external nasal branch inner-
In the infraorbital canal. After crossing the upper vates the skin of the lateral surface of the nose. The
part of the PPF, the maxillary nerve (V2) inclines later- internal nasal branch emerged through the medial
ally and then enters the infraorbital groove and canal portion of the infraorbital foramen and descended
and continues as the infraorbital nerve (ION) (Figs. 8B down the face along the nose and around the ala of
and 8D). The average lengths of the groove and canal the nose (Fig. 9F). Finally, it supplied the nasal sep-
were 12 mm (range, 522 mm) and 14 mm (range, tum and vestibule of the nose. The nasal branches
722 mm), respectively (Rahman et al., 2009). The join with external branches of the anterior ethmoidal
long axis of the infraorbital canal is directed downward nerve (Gray and Williams, 1989b; Hu et al., 2006).
and medially across the face (Fig. 9D). The ION runs Superior labial branches. The superior labial
in its canal lying progressively below the oor of the branches, large and numerous, descend posterior to
orbit, in the roof of the maxillary sinus, until it the levator labii superior muscle to supply the skin of
emerges in the face through the infraorbital foramen the anterior part of the cheek, upper lip, oral mucosa,
located below the inferior orbital rim. The ION and labial gland and are joined by zygomatic branch
branches into middle and anterior superior alveolar of the facial nerve to form the infraorbital plexus (Fig.
nerves within the infraorbital canal (Fig. 9F). 9F) (Gray and Williams, 1989b).
Middle superior alveolar nerve. The middle
superior alveolar nerve leaves the ION in the infraor-
bital groove, the posterior part of the infraorbital canal Mandibular Division
(Fig. 9C). It runs down and forward in the lateral wall
of the maxillary sinus and ends in small branches The mandibular division (V3) is the largest of the
which link up with the superior dental plexus, supply- three divisions of the trigeminal nerve. It supplies the
ing small rami to the upper premolar teeth. The mid- teeth, gums of the mandible, the skin in the temporal
dle superior alveolar also anastomoses with the region, part of the auricle, the lower lip, and the lower
posterior superior alveolar nerve (Shankland, 2001b). part of the face. However, unlike the ophthalmic (V1)
Anterior superior alveolar nerve. The anterior and maxillary (V2) divisions which convey purely
superior alveolar nerve, being larger than middle afferent bers, the V3 also contains motor or efferent
superior alveolar nerve, leaves the lateral side of the ber to innervate the muscle that are attached to
ION just prior to the infraorbital exit through the fora- mandibule, including the muscle of mastication, the
men (Fig. 9G). It traverses the canal in the anterior mylohyoid, the anterior belly of the digastric muscle,
wall of maxillary sinus and divides into branches sup- tensor veli palatini, and tensor tympani muscle.
plying incisor and canine teeth. It communicates with The V3, which is the largest division of the trigemi-
middle alveolar nerve to form the superior dental nal nerve, is made up of two roots: a large, sensory
plexus and gives rise to nasal branch, which passes root, which proceeds from the lateral part of the tri-
through a small canal in the lateral wall of the inferior geminal ganglion and emerges almost immediately
meatus to supply the mucous membrane of the ante- through the foramen ovale of the sphenoid bone and
rior area of the lateral wall and the oor of the nasal a small motor root arising around the superomedial
cavity (Gray and Williams, 1989b; Shankland, part of the main sensory root in the pons that passes
2001b). below the trigeminal ganglion and unites with the sen-
On the face. The infraorbital nerve (ION), an sory root just outside the foramen ovale (Figs. 2B, 2C,
entirely sensory nerve, is the terminal branch of the and 5D). The V3 exits the middle fossa through the
maxillary nerve (V2). When it emerges onto the face foramen ovale to enter the infratemporal fossa and
through the infraorbital foramen, which is normally medial to the lateral pterygoid muscle where the main
Fig. 10. A. Superolateral view of the right infratem- joins the lingual nerve. E. The lateral pterygoid muscle
poral fossa. The middle fossa oor has been removed to has been removed to pterygoid nerves. The medial pter-
expose the branches of the mandibular nerve. The mas- ygoid nerve originates from the medial aspect of the
seteric and deep temporal nerves pass above the ptery- main trunk below the foramen ovale close to the otic
goid venous plexus and the upper head of the lateral ganglion. The tenso veli palatini muscle is located medial
pterygoid muscle. B. The mandibular ramus has been to the branches of the mandibular nerve. F. The lesser
removed to pterygoid muscles. The buccal nerve passes petrosal nerve emerging through the roof of the tym-
anterolaterally between the upper and lower heads of panic cavity of the temporal bone passes along the ten-
the lateral pterygoid muscles. C. The mandibular condyle sor tympani muscle anterolaterally to enter the otic
and the lateral pterygoid muscle have been reected ganglion. Abbreviations: A., artery; Acc., accessory; Alv.,
anteriorly to expose the branches of the maxillary artery alveolar; Auri. Temp. N., auriculotemporal nerve; Br.,
and mandibular nerve. The auriculotemporal nerve runs branch; Chor.Tym. N., chorda tympani nerve; CN., cra-
backward medial to the lateral pterygoid muscle to the nial nerve; For., foramen; GSPN., greater supercial
neck of the mandible. The middle meningeal artery petrosal nerve; Inf., inferior; Lat., lateral; LSPN., lesser
passes between the two roots of the auriculotemporal supercial petrosal nerve; M., muscle; Max., maxillary;
nerve. D. Enlarged view of the branches of the mandibu- Med., medial; MMA., middle meningeal artery; N., nerve;
lar nerve. The anterior division of the mandibular nerve Plex., plexus; Ptery., pterygoid; Spin., spinosum; Sph.
passes in the horizontal plane just below the pericranium Mand. Lig., sphenomandibular ligament; Supf., super-
of the infratemporal surface of the middle cranial fossa. cial; Temp., temporal; Ten. Tym. M., tensor tympani
The chorda tympani nerve enters the infratemporal fossa muscle; Ten. Vel. Pal. M., tensor veli palatini muscle.
through the petrotympanic ssure, descends medial to [Color gure can be viewed in the online issue, which is
the auriculotemporal and inferior alveolar nerves, and available at wileyonlinelibrary.com.]
80 Joo et al.

Fig. 11.
Microsurgical Anatomy of the Trigeminal Nerve 81

trunk divides into a small anterior division and a large Medial pterygoid nerve. The medial pterygoid
posterior division (Figs. 10A10C). nerve arises from the medial aspect of the main
The infratemporal fossa is a deep-seated space trunk below the foramen ovale close to the otic gan-
below the infratemporal crest, which continues superi- glion and descends to supply the medial pterygoid
orly to the temporal fossa including the temporal mus- muscle (Figs. 10E and 11C). It contains sensory,
cle and inferiorly to parapharyngeal space. The motor, and proprioceptive ber of the medial ptery-
osseous boundaries of the infratemporal fossa are the goid muscle.
posterolateral maxillary surface anteriorly, the lateral Tensor veli palatini nerve. The nerve to the ten-
pterygoid plate anteromedially, the mandibular ramus sor veli palatini arises from the medial aspect of the
laterally, and the tympanic part of the temporal bone main trunk like the medial pterygoid nerve. It passes
and the styloid process posteriorly (Figs. 7C and 7D). through otic ganglion to innervate the tensor veli pala-
This fossa contains the maxillary artery, the mandibu- tini near its origin at the base of the medial pterygoid
lar branch (V3) of the trigeminal nerve, the pterygoid plate of the sphenoid bone (Shankland, 2001c).
muscles, and the pterygoid venous plexus (Figs. 10A, Tensor tympani nerve. The nerve to the tensor
10B, 11A, and 11C). Topographically, the mandibular tympani may arise separately or in common with the
division is located intimately to the lateral pterygoid tensor veli palatini nerve from the undivided main
muscle and some mandibular nerve branches pass trunk. It passes through the otic ganglion without
through the lateral pterygoid muscle (Figs. 10A and interruption. The nerve pierces the cartilage of the
10B). auditory tube to enter the tensor tympani muscle
Undivided trunk. The small motor root originates (Kierner et al., 2003; Shankland, 2001c).
in the pons, passes below the trigeminal ganglion, Otic ganglion. The otic ganglion is a small, oval,
and unites with the large sensory root just outside the at, and reddish gray ganglion situated immediately
foramen ovale, where main trunk of the V3 lies below the foramen ovale (Fig. 11C). It lies on the
between the tensor veli palatini medially and the lat- medial surface of the mandibular undivided trunk near
eral pterygoid muscle laterally (Figs. 10C, 10E, and the origin of the medial pterygoid and tensor veli pala-
11B). Immediately beyond the junction of the two tini nerves. This ganglion is a peripheral parasympa-
roots, the main trunk (V3) gives rise to the meningeal thetic ganglion intimately related topographically to
branch and the nerve to the medial pterygoid muscle the mandibular nerve but functionally connected with
from the medial aspect and then divides into a smaller the glossopharyngeal nerve (Fig. 1D). The pregan-
anterior trunk and a larger posterior trunk (Fig. 10E). glionic parasympathetic bers leave the inferior sali-
Meningeal branch. The meningeal branch, a nerv- vary nucleus of the glossopharyngeal nerve in the
ous spinosus, arises near the otic ganglion and brain stem. It enters the tympanic branch, which
ascends through the foramen spinosum with the mid- passes through a small canal in the carotid ridge
dle meningeal artery to innervate the middle cranial between the jugular foramen and carotid canal to
fossa dura. It divides into anterior and posterior reach the tympanic cavity, passes through the tym-
branches, which accompany the main division of the panic plexus and emerges through the roof of the
artery. The nervous spinosus contains sympathetic tympanic cavity of the temporal bone as the lesser
postganglionic bers from the middle meningeal supercial petrosal nerve (LSPN). The LSPN proceeds
plexus (Gray and Williams, 1989b). to the otic ganglion (Figs. 10D and 10F).

Fig. 11. A. Coronal section just behind the pterygo- the ramus of the mandible (removed). E. The masseter
palatine fossa. The right lateral pterygoid muscle has muscle has been removed from the mandible to expose
been removed from the pterygoid venous plexus and the masseter nerve. The masseter nerve passes laterally
posterior division of the mandibular nerve. The nerve to above the lateral pterygoid muscle in front of the tempo-
the lateral pterygoid muscle originates from the buccal romandibular joint and behind the tendon of the tempo-
nerve passing between the two heads of the lateral pter- ral muscle. It runs to the deep surface of the master
ygoid. B. The right pterygoid venous plexus and ptery- muscle. F. The mandibular ramus has been removed to
goid plates have been removed to expose the branches expose the lingual and the inferior alveolar nerves. G.
of the mandibular nerve. The posterior division of the Anterior view of the right cheek. The buccal nerve
mandibular nerve descends between the lateral ptery- emerges from the undersurface of the ramus of mandi-
goid muscle (removed) and tensor veli palatini muscle ble and unites with the buccal branches of the facial
(cut). The palatovaginal canal is located media to the nerve. Abbreviations: Acc. MMA., Accessory middle
vidian canal. C. Enlarged view of the proximal portion of meningeal artery; Ant., anterior; Alv., alveolar; Auri.
the right mandibular nerve. The nerve to the medial Temp. N., auriculotemporal nerve; Br., branch; Chor.-
pterygoid muscle arises from the medial aspect of the Tym. N., chorda tympani nerve; CN., cranial nerve;
mandibular nerve close to the otic ganglion. D. Lateral Eust., Eustachian; Gang., ganglion; Inf., inferior; Lat.,
view of the right infratemporal fossa. The mandibular lateral; Lev. Vel. Pal. M., levator veli palatini muscle; M.,
ramus and lateral pterygoid muscle have been removed. muscle; Med., medial; N., nerve; Pal. Vag., palatovagi-
The buccal, deep temporal, and masseter nerves have nal; Sph. Mand. Lig., sphenomandibular ligament;
been elevated with the dissector. This division passes in Temp., temporal; Ten. Vel. Pal. M., tensor veli palatini
the horizontal plane. The auriculotemporal nerve passes muscle. [Color gure can be viewed in the online issue,
backward between the sphenomandibular ligament and which is available at wileyonlinelibrary.com.]
82 Joo et al.

After synapsing on cell in the ganglion, postgan- trunk. The nerve branches arising from the auriculo-
glionic parasympathetic secretomotor bers reach to temporal or masseteric nerve did not innervate the
the parotid gland via the auriculotemporal nerve (Figs. lateral pterygoid muscle (Kim et al., 2003).
10C, 12C, and 12D). The sympathetic root arises Masseter nerve. The massetric nerve passes later-
from the plexus on the middle meningeal artery. It ally above the lateral pterygoid muscle in front of the
contains postganglionic bers from the superior cervi- temporomandibular joint and behind the tendon of the
cal sympathetic ganglion, which traverse the otic gan- temporal muscle (Fig. 10A). It crosses the posterior
glion without synapse. The sympathetic ber supplies part of the mandibular notch with the masseteric
the blood vessels in the parotid gland (Shankland, artery and runs to the deep surface of the masseter
2000). muscle (Figs. 11D and 11E). The masseteric nerve
Anterior division. The V3 divides into the anterior gives off anterior and posterior branches in the short
smaller and the posterior larger divisions in the infra- masseter muscle. The anterior branch is larger and
temporal fossa. The average distance of the undivided longer than the posterior one (Figs. 11E and 11F)
trunk from the foramen ovale to the bifurcation of the (Hwang et al., 2005). The masseteric nerve is the
V3 was approximately 7.7 mm (range, 512 mm) most posterior branch among the anterior division of
(Vrionis et al., 1996). The smaller anterior division the V3 (Figs. 10A and 11D).
gives rise to the sensory buccal nerve and the motor The motor nerve to the masseter was found 3.16 6
branches: masseteric nerve, deep temporal nerves, 0.30 cm anterior to the tragus and 1.08 6 0.18 cm
and nerve to the lateral pterygoid muscle. This divi- inferior to the caudal edge of the zygomatic arch. Rel-
sion passes in the horizontal plane just below the peri- ative to the zygomatic arch, the nerve formed an
cranium of the infratemporal surface of the middle angle of 50 6 7.6 as it coursed distally into the mass-
cranial fossa (Fig. 10A). eter muscle (Borschel et al., 2012).
Buccal nerve. The sensory buccal nerve passes Deep temporal nerves. The anterior and posterior
anterolaterally between the two heads of the lateral branches of the nerves usually pass above the lateral
pterygoid, below the inferior portion of the temporal pterygoid muscle to enter the deep surface of the
muscle, and deep to the mandible and the masseter temporalis muscle (Fig. 10A) (Gray and Williams,
muscle (Figs. 10A, 10B, and 11A). Its course is 1989a). Kwak et al. reported that the anterior deep
directed between the coronoid process and tuberosity temporal nerve passes between the superior and infe-
of the maxilla. It emerges from the undersurface of rior heads of the lateral pterygoid muscle, courses
the ramus of the mandible and the anterior border of anteriorly in the infratemporal fossa, and then turns
the masseter muscle and unites with the buccal superiorly, passing into the temporal fossa on the lat-
branches of the facial nerve (Figs. 11E11G) (Gray eral aspect of the skull to enter the deep surface of
and Williams, 1989b). The buccal nerve conveys sen- the anterior portion of the temporal muscle. The pos-
sory innervation to the buccinators muscle, buccal terior deep temporal nerves ran on the superior sur-
mucosa, and the skin of the corner of the mouth. It face of the superior head and distributed into the
normally pierces the posterior half of the buccinators posterior portion of the temporalis muscle (Figs. 12A
muscle to arborize extensively on the buccal surface and 12B). In all specimens, the anterior deep tempo-
of the cheek (Tubbs et al., 2010). However, some ral nerve arose from the buccal nerve, being one or
authors reported that the buccal nerve was a mixed two in number (Fig. 12B) (Kwak et al., 2003; Shank-
nerve, which provide the branches to the lateral ptery- land, 2001c). The posterior branch, generally two or
goid muscle and temporal muscle (Kim et al., 2003; three in number, arises in common with the masse-
Piagkou et al., 2011; Davies et al., 2012). teric nerves (Akita et al., 2000; Gray and Williams,
The buccal nerve was found to lie 3 cm lateral to 1989a).
the angle of the mouth (range, 2.83.3 cm). It was Posterior division. The large posterior division of
located 7 mm caudally from the point of entrance of the V3 is mainly sensory but receives a few laments
the parotid duct into the buccinators muscle (range, from the motor root. It divides into three main
412 mm) (Figs. 11E and 11G) (Tubbs et al., 2010). branches: the auriculotemporal nerve, the inferior
Lateral pterygoid nerve. The lateral pterygoid alveolar nerve, and the lingual nerve which descend in
nerve enters the deep surface of the muscle (Figs. the sagittal plane toward the lower face structures
10E and 11D). It is generally described that the nerve (Figs. 10C, 10D, and 11D).
to the lateral pterygoid nerve originates mainly from Auriculotemporal nerve. The auriculotemporal
the buccal nerve (Fig. 11A) (Gray and Williams, nerve originates from the posterior trunk of the V3
1989a; Kim et al., 2003; Piagkou et al., 2011). It is primarily in two branches and the middle meningeal
the most inconsistent of all the individual branches of artery passes between them (Gray and Williams,
the entire trigeminal nerve (Shankland, 2001c). Fou- 1989b; Joo et al., 2013; Schmidt et al., 1998). Encir-
cart et al. (1998) reported that the lateral pterygoid cling the middle meningeal artery, these roots join
muscle is innervated by one to three branches from and run backward deep to the lateral pterygoid mus-
the anterior trunk of the mandibular nerve and addi- cle on the surface of the tensor veli palatini to pass
tionally by branches from the buccal, auriculotomepo- between the sphenomandibular ligament and the neck
ral, and masseteric nerves (Foucart et al., 1998). of the mandible (Figs. 10C, 10D, 11C, and 11D). How-
However, according to Kim et al. the lateral pterygoid ever, Gu lekon et al. (2005) reported that single root
muscle was observed to be innervated not only by the of the auriculotemporal nerve in 16 specimens (50%),
buccal nerve but also by the deep temporal nerves two roots in 12 specimens (37.5%), three roots in 3
and branches directly from the mandibular nerve specimens (9.4%), and four roots in 1 specimen
Microsurgical Anatomy of the Trigeminal Nerve 83

Fig. 12. A. Superior view after removing the bone branches and ascends in the parotid gland between the
of middle fossa. The posterior deep temporal nerve runs temporomandibular joint and external acoustic meatus.
on the superior surface of the superior head of the lat- It communicates with facial nerve at the posterior bor-
eral pterygoid muscle. The masseter nerve is the most der of the mandibular ramus. E. Lateral view of the right
posterior branch among the anterior division of the preauricular area. The auriculotemporal nerve ascends
mandibular nerve. B. The squamous portion of the tem- posterior to the supercial temporal artery over the pos-
poral bone has removed to expose deep surface of the terior root of zygoma. The frontal branches of the facial
temporal muscle. The anterior deep temporal nerve nerve pass over the zygomatic arch. Abbreviations: A.,
passes between the superior and inferior heads of the artery; Ac., acoustic; Ant., anterior; Auri. Temp. N.,
lateral pterygoid muscle. The deep temporal nerves auriculotemporal nerve; Br., branch; Ext., external;
enter the deep surface of the anterior portion of the Gang., ganglion; Gl., gland; Inf. Alv. N., inferior alveolar
temporal muscle. C. Enlarged view of the right infratem- nerve; Lat., lateral; M., muscle; Mand. For., mandibular
poral fossa. The middle meningeal artery passes foramen; Max., maxillary; Med., medial; N., nerve;
between the two roots of the auriculotemporal nerve. Post., posterior; Post. Auri. A., posterior auricular
The auriculotemporal nerve runs medial to lateral artery; Ptery., pterygoid; STA., supercial temporal
behind the neck of the mandible. D. Lateral view of the artery; Sup., superior; Temp., temporal; Tr., trunk.
right mandibular neck area. The parotid gland has [Color gure can be viewed in the online issue, which is
removed to expose the auriculotemporal and facial available at wileyonlinelibrary.com.]
nerves. The auriculotemporal nerve gives off the parotid
84 Joo et al.

(3.1%) were detected in 32 infratemporal fossa of 16 age distance between the foramen ovale and the
cadaveric heads (Gu lekon et al., 2005). bifurcation of lingual and inferior alveolar nerve was
The auriculotemporal nerve runs medial to lateral 8.7 mm (range, 014 mm). They found high bifurca-
behind the neck of the mandible, gives off parotid tion which consists of the bifurcation of the V3 with
branches, and changes its direction upward in the the lingual nerve above the foramen ovale (Shinohara
parotid gland between the temporomandibular joint et al., 2010). At rst, the lingual nerve runs down
and the external acoustic meatus (Fig. 12D). Emerg- between the tensor veli palatini and the lateral ptery-
ing from behind the joint, it ascends posterior to the goid muscles (Figs. 10C, 10D, 11A, and 13D). At the
supercial temporal vessels, over the posterior root of inferior border of the lateral pterygoid, the nerve is
the zygoma, and divides into supercial temporal joined by the chorda tympani branch of the facial
branches (Figs. 12D and 12E). The nerve was always nerve, which contains both sensory bers from the
found to be lateral to the supercial temporal artery in geniculate ganglion and preganglionic parasympa-
the upper preauricular region of the temple in the dis- thetic bers and often by a branch of the inferior alve-
sections of 25 fresh cadaveric heads (Janis et al., olar nerve (Figs. 10C, 10F, and 11C). Beyond this
2010). point, the lingual nerve contains bers for general
The auriculotemporal nerve contains somatosen- sensation that are true trigeminal nerve bers, bers
sory and secretomotor bers of CN V3 and CN IX for taste derived from the facial nerve, and autonomic
(Loughner et al., 1990). It conveys secretomotor bers destined for the submandibular ganglion (Fig.
bers to the parotid gland. The preganglionic para- 1D) (Hollinshead, 1982b). The lingual nerve courses
sympathetic bers leave the glossopharyngeal nerve down and forward between the mandibular ramus and
by way of its tympanic branch to join the tympanic the medial pterygoid, lying anterior and slightly deep
plexus on the promontory of the middle ear cavity, to the inferior alveolar nerve, with which it may com-
subsequently leaving the plexus through the lesser municate (Figs. 10B, 10C, and 11B). It then passes
petrosal nerve; this nerve ends in the otic ganglion, inferiorly to the attachment of the superior constrictor
where the preganglionic bers make synapse (Fig. at the posterior end of the mylohyoid line, where it is
1D). The otic ganglion lies just outside the foramen covered only by the gingival mucosa (Benninger et al.,
ovale on the medial surface of the mandibular nerve 2012). According to some reports, the average dis-
and gives off laments to the roots by which the tance from the lingual alveolar crest to the lingual
auriculotemporal nerve arises from the mandibular nerve was 4.45 mm in the retromolar region (Pogrel
nerve; these bers then leave the auriculotemporal et al., 1995), and the average distance in the third
nerve with sensory bers to form the parotid branches molar region was 2.28 mm (Kiesselbach and Cham-
of this nerve and reach the gland. The auriculotempo- berlain, 1984). It leaves the gingiva and passes on to
ral nerve is also closely associated with the facial the side of the tongue, where it crosses the styloglos-
nerve. It communicates with the facial nerve at the sus and runs on the lateral surface of the hyoglossus
posterior border of the mandibular ramus where the and deep to the mylohyoid, above the deep part of
auriculotemporal nerve passes posterior to the neck the submandibular gland and its duct (Figs. 13A and
of the condyle and facial nerve divides into two major 13B). The lingual nerve proceeds forward on the side
branches in the parotid gland after exiting the stylo- of the tongue, lateral to the hyoglossus and genioglos-
mastoid foramen (Fig. 12D). Occasionally, connecting sus, and divides into terminal branches which lie
branches may be seen between the auriculotemporal directly under the lingual mucosa (Gray and Williams,
and inferior alveolar nerves in the temporomandibular 1989b). The nerve distribution in the tongue is
region (Gu lekon et al., 2005; Janis et al., 2010). actually more complicated. The nerve bers are com-
Literature review showed that the study of Baumel plexly intermingled, and communication between the
et al. presents the most comprehensive quantitative lingual and the hypoglossal nerve have been reported
data on the variations of the auriculotemporal nerve (Shinohara et al., 2010).
(Baumel et al., 1971). The lengths of the roots were Most of the parasympathetic bers leave the lingual
15 mm (range, 523 mm). The distances between the nerve at the level of the submandibular gland to end
roots were 6 mm (range, 113 mm). The upper root in the submandibular ganglion, suspended from the
is usually located lateral to the middle meningeal nerve as it courses just above the gland; the bers
artery and the lower root is located medially (Figs. from the ganglion are distributed to the submandibu-
10C and 12C) (Baumel et al., 1971).The average lar and sublingual glands, while the sensory bers in
length of the posterior trunk from foramen ovale to the lingual nerve are distributed to the anterior two
origin of the upper root of the auriculotemporal nerve third of the tongue (Figs. 1D and 13A).
was 3.3 mm (range, 17.5 mm) (Joo et al., 2013). Inferior alveolar nerve. The inferior alveolar
Lingual nerve. The lingual nerve is the main nerve is the largest branch of the mandibular division
branch of the posterior division of V3 that provides of the trigeminal nerve. The nerve usually gives four
sensation to the anterior two-thirds of the tongue and distributing branches and some communicating
gingiva variably along the lingual side of the mandibu- branches, three of which are sensory branches and
lar teeth. Within the infratemporal fossa, the lingual one a motor branch. Sensory branches are the incisive
nerve arises from the posterior division of V3. The nerve, the mental nerve, and the nerve to the lower
average length of the posterior trunk from the fora- premolars and molars. The motor branch is the nerve
men ovale to the bifurcation into lingual and inferior to the mylohyoid (Figs. 13C13E). The inferior alveo-
alveolar nerve was 13.5 mm (range, 632 mm) (Joo lar nerve arises from the posterolateral surface of the
et al., 2013). Shinohara et al. reported that the aver- main mandibular trunk and descends deep to the
Fig. 13. A. Inferolateral view of the right submandib- alveolar nerve gives rise to the mylohyoid nerve before it
ular area. The facial nerves run over the submandibular enters the mandibular foramen. It then emerges in the
gland which lie on the digastric tendon. B. Enlarged view submandibular triangle and supplies both mylohyoid and
of the right submandibular triangle. The submandibular anterior belly of the digastric muscles. E. The angle of
gland has been removed to expose the contents of the mandible has been removed. The mylohyoid nerve runs
submandibular triangle. After passing between the man- down and forward between the mandible and the medial
dibular ramus and the medial pterygoid muscle, the lin- pterygoid muscle and lodges in the mylohyoid groove.
gual nerve crosses the styloglossus muscle and runs The buccal nerve emerges from the undersurface of the
between the hyoglossus and mylohyoid muscles above ramus of the mandible. Abbreviations: A., artery; Alv.,
the deep part of the submandibular gland. C. Lateral view alveolar; Ant., anterior; Car., carotid; CN., cranial nerve;
of the right infratemporal fossa. The lingual nerve courses Eust., Eustachian; Gl., gland; Inf., inferior; Int., internal;
down and forward between the mandibular ramus Lat., lateral; Lev. Vel. Pal. M., levator veli palatini muscle;
(removed) and medial pterygoid muscle, lying anterior M., muscle; Max., maxillary; Med., medial; N., nerve;
and slightly deep to the inferior alveolar nerve. The sphe- Ptery., pterygoid; Sph. Mand. Lig., sphenomandibular lig-
nomandibular ligament is a at, thin band descending ament; STA., supercial temporal artery; Temp., tempo-
from the sphenoidal spine and widening to reach the lin- ral; Ten. Vel. Pal. M., tensor veli palatini muscle. [Color
gual of the mandibular foramen. D. Anterior view of the gure can be viewed in the online issue, which is available
right infratemporal fossa. The lingual nerve is anterior at wileyonlinelibrary.com.]
and medial to the inferior alveolar nerve. The inferior
86 Joo et al.

lateral pterygoid muscle and then, at the lower border lingual nerve by anterior and posterior laments (Figs.
of the muscle, it passes between the sphenomandibu- 13A and 13B). Although the ganglion is related to the
lar ligament and the ramus of the mandible to the lingual nerve, it is connected functionally with the
mandibular foramen (Figs. 7E, 7F, 10C, 10F, and facial nerve and chorda tympani. The preganglionic
13C). The distance from the mandibular notch to the parasympathetic bers leave the superior salivatory
mandibular foramen was 17.4 mm (range, 1520 nucleus of facial nerve in the brain stem. It enters the
mm) (Joo et al., 2013). Below the lateral pterygoid, it chorda tympani which leaves the facial nerve above
is accompanied by the inferior alveolar artery arising the stylomastoid foramen and takes a recurrent
from the maxillary artery (Fig. 13E). The inferior alve- course upward and forward in its canaliculus to enter
olar nerve enters the mandibular foramen slightly the tympanic cavity through its posterior wall. It
anterior and superior to the inferior alveolar artery. crosses the upper aspect of the tympanic membrane
The length of the inferior alveolar nerve before it between malleus and incus and leaves the cavity
enters the mandibular foramen was 31.1 mm (range, through a canal in the petrotympanic ssure. It then
1344 mm) (Joo et al., 2013). The nerve passes joins the posterior aspect of the lingual nerve at an
through the body of the mandible, sometimes acute angle (Figs. 10F and 11C). The chorda tympani
enclosed by a thick connective tissue sheath within contains preganglionic parasympathetic secretomotor
the bony canal, and gives off branches to the teeth bers which enter the submandibular ganglion, from
which may form a plexus between the trunk of the which postganglionic bers are relayed to the sub-
nerve and the roots of the teeth (Zoud and Doran, mandibular and sublingual glands (Fig. 1D).
1993). The sympathetic root is derived from the plexus on
The inferior alveolar nerve gives off the mylohyoid the facial artery. It contains postganglionic bers from
nerve just before it enters the mandibular foramen the superior cervical ganglion, which traverse the sub-
(Figs. 13D and 13E). The nerve to the mylohyoid mandibular ganglion without synapse. They are vaso-
nerve pierces the sphenomandibular ligament, runs motor to the blood vessels of the submandibular and
downward and forward below the mylohyoid line, a sublingual glands.
groove on the ramus of the mandible. It then appears
in the digastric triangle and supplies both the mylo-
hyoid and anterior belly of the digastric muscle (Gray CONCLUSIONS
and Williams, 1989b; Kumar et al., 2011; Shankland,
2001c). However, Kumar et al. (2011) reported that The trigeminal nerve is the largest cranial nerve
they found the nerve to the mylohyoid nerve, which and contains both sensory and motor components. It
arose from the trunk of the mandibular nerve and is encountered with imaging or surgery of the skull
passed posteromedial to the inferior alveolar nerve in base surgery. With advancement of the surgical pro-
ve of 50 southern Indian cadavers (Kumar et al., cedures, many of the lesions involving the trigeminal
2011). Recently, Kim et al. (2004) described commu- nerve can be treated surgically. Thus, a comprehen-
nication between the mylohyoid and lingual nerve in sive knowledge of the anatomy of the trigeminal
12.5% of examined cases and they rst mentioned nerve is crucial for performing the surgical procedures
that this communication could provide another route without signicant complication.
for collateral sensory transmission to the tongue (Kim
et al., 2004).
The dental branches of the inferior alveolar nerve
supply the molar, premolar, incisor, and canine teeth.
ACKNOWLEDGMENTS
Before they enter the dental root, they communicate We gratefully acknowledge the cadaver donors.
and form an inferior dental plexus, which is located
between the mandibular canal and the roots of the
mandibular teeth. The mental nerve, pure sensory, is REFERENCES
a large branch of the inferior alveolar nerve that
leaves the interior of the mandible to supply the skin Akita K, Shimokawa T, Sato T. 2000. Positional relationships
of the chin and lower lip, the mucosa of the lip, and between the masticatory muscles and their innervating nerves
with special reference to the lateral pterygoid and the midmedial
the adjacent gum. The mental foramen may usually
and discotemporal muscle bundles of temporalis. J Anat 197:
be found on the vertical line drawn downward from 291302.
the supraorbital notch and lies below the level of pre- Al-Mefty O, Ayoubi S, Gaber E. 2002. Trigeminal schwannomas:
molar teeth (Fig. 7E) (Hollinshead, 1982b). The men- removal of dumbbell-shaped tumors through the expanded
tal nerve, emerging from its foramen, divides beneath Meckel cave and outcomes of cranial nerve function. J Neurosurg
the depressor anguli oris into three: a branch 96:453463.
descending to the skin of the chin and two ascending Aleri A, Jho HD, Schettino R, Tschabitscher M. 2003. Endoscopic
to the skin and mucosa of the lower lip. These endonasal approach to the pterygopalatine fossa: Anatomic
branches communicate with mandibular branch of the study. Neurosurgery 52:374378; discussion 378380.
Arslan M, Deda H, Avci E, Elhan A, Tekdemir I, Tubbs RS, Silav G,
facial nerve.
Yilmaz E, Baskaya MK. 2012. Anatomy of Meckels cave and the
Submandibular ganglion. This peripheral para- trigeminal ganglion: Anatomical landmarks for a safer approach
sympathetic ganglion is a small, fusiform body, which to them. Turk Neurosurg 22:317323.
lies on the upper part of the hyoglossus. It situates Barakos JA, DAmour PG, Dillon WP, Newton TH. 1990. Trigeminal
superior to the deep part of the submandibular gland sensory neuropathy caused by cervical disk herniation. AJNR Am
and inferior to the lingual nerve, suspended from the J Neuroradiol 11:609.
Microsurgical Anatomy of the Trigeminal Nerve 87

Baumel JJ, Vanderheiden JP, McElenney JE. 1971. The auriculotem- for the treatment of migraine headaches. Plast Reconstr Surg
poral nerve of man. Am J Anat 130:431440. 125:14221428.
Benninger B, Kloenne J, Horn JL. 2012. Clinical anatomy of the lin- Jannetta PJ. 1996. Trigeminal neuralgia: Treatment by microvascular
gual nerve and identication with ultrasonography. Br J Oral Max- decompression. In: Wilkins RH, Rengachary SS, editors. Neuro-
illofac Surg 51:541544. surgery. 2nd Ed. New York: McGraw-Hill. p 39613968.
Borschel GH, Kawamura DH, Kasukurthi R, Hunter DA, Zuker RM, Jeong SM, Park KJ, Kang SH, Shin HW, Kim H, Lee HK, Chung YG.
Woo AS. 2012. The motor nerve to the masseter muscle: an 2010. Anatomical consideration of the anterior and lateral cuta-
anatomic and histomorphometric study to facilitate its use in neous nerves in the scalp. J Korean Med Sci 25:517522.
facial reanimation. J Plast Reconstr Aesthet Surg 65:363366. Joo W, Funaki T, Yoshioka F, Rhoton AL Jr. 2013. Microsurgical anat-
Carpenter MB. 1991a. Blood supply of the central nervous system. omy of the infratemporal fossa. Clin Anat 26:455469.
In: Carpenter MB, editor. Core Text of Neuroanatomy. 4th Ed. Kapila A, Chakeres DW, Blanco E. 1984. The Meckel cave: computed
Baltimore: Williams & Wilkins. p 434462. tomographic study. Part I: Normal anatomy; Part II: Pathology.
Carpenter MB. 1991b. The pons. In: Carpenter MB, editor. Core Text Radiology 152:425433.
of Neuroanatomy. 4th Ed. Baltimore: Williams & Wilkins. p 151 Kawase T, van Loveren H, Keller JT, Tew JM. 1996. Meningeal archi-
191. tecture of the cavernous sinus: Clinical and surgical implications,
Cuzalina AL, Holmes JD. 2005. A simple and reliable landmark for Neurosurgery 39:527534; discussion 526534.
identication of the supraorbital nerve in surgery of the fore- Kehrli P, Maillot C, Wolff MJ. 1997. Anatomy and embryology of the
head: An in vivo anatomical study. J Oral Maxillofac Surg 63:25 trigeminal nerve and its branches in the parasellar area. Neurol
27. Res 19:5765.
Davies JC, Charles M, Cantelmi D, Liebgott B, Ravichandiran M, Kierner AC, Mayer R, Adunka O. 2003. Is there a double innervation
Ravichandiran K, Agur AM. 2012. Lateral pterygoid muscle: A of the tensor tympani muscle in humans? Ann Otol Rhinol Laryn-
three-dimensional analysis of neuromuscular partitioning. Clin gol 112:10561058.
Anat 25:576583. Kiesselbach JE, Chamberlain JG. 1984. Clinical and anatomic obser-
Day JD, Giannotta SL, Fukushima T. 1994. Extradural temporopolar vations on the relationship of the lingual nerve to the mandibular
approach to lesions of the upper basilar artery and infrachias- third molar region. J Oral Maxillofac Surg 42:565567.
matic region. J Neurosurg 81:230235. Kim HJ, Kwak HH, Hu KS, Park HD, Kang HC, Jung HS, Koh KS.
Dodd J, Kelly JP. 1991. The trigeminal system. In: Kandel ER, 2003. Topographic anatomy of the mandibular nerve branches
Schwartz JH, Jessell TM, editors. Principles of Neural Science. distributed on the two heads of the lateral pterygoid. Int J Oral
3rd Ed. New York: Elsevier. Maxillofac Surg 32:408413.
Dolenc VV. 1989. Anatomy of the Cavernous Sinus. Wien; New York: Kim HS, Kim DI, Chung IH. 1996. High-resolution CT of the pterygo-
Springer-Verlag. p. 37. palatine fossa and its communications. Neuroradiology 38(Suppl
el Shazly MA. 1991. Endoscopic surgery of the vidian nerve. Prelimi- 1):S120S126.
nary report. Ann Otol Rhinol Laryngol 100:536539. Kim SY, Hu KS, Chung IH, Lee EW, Kim HJ. 2004. Topographic anat-
Fix JD. 1995. Gross anatomy of the brain. In: Fix JD, editor. Neuro- omy of the lingual nerve and variations in communication pattern
anatomy. 2nd Ed. Baltimore: Williams & Wilkins. p 131. of the mandibular nerve branches. Surg Radiol Anat 26:128
Foucart JM, Girin JP, Carpentier P. 1998. Innervation of the human 135.
lateral pterygoid muscle. Surg Radiol Anat 20:185189. Kumar S, Kumar CJ, Bhat S, Kumar A. 2011. Anatomical study of
Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren the unusual origin of a nerve to the mylohyoid muscle and its
HR, Keller JT. 2007. Renement of the extradural anterior clinoi- clinical relevance. Br J Oral Maxillofac Surg 49:e14e15.
dectomy: surgical anatomy of the orbitotemporal periosteal fold, Kunc Z, Ceskoslovenska  akademie ve  d. 1964. Tractus spinalis nervi
Neurosurgery 61:179185; discussion 185176. trigemini: Fresh anatomic data and their signicance for surgery.
Gu lekon N, Anil A, Poyraz A, Peker T, Turgut HB, Karako se M. 2005. Praha: Nakladatelstv Ceskoslovenske  akademie ve d.
Variations in the anatomy of the auriculotemporal nerve. Clin Kwak HH, Ko SJ, Jung HS, Park HD, Chung IH, Kim HJ. 2003. Topo-
Anat 18:1522. graphic anatomy of the deep temporal nerves, with references to
Go JL, Kim PE, Zee CS. 2001. The trigeminal nerve. Semin Ultra- the superior head of lateral pterygoid. Surg Radiol Anat 25:393
sound CT MR 22:502520. 399.
Govsa F, Kayalioglu G, Erturk M, Ozgur T. 1999. The superior orbital Lang J. 1981. [Neuroanatomy of the optic, trigeminal, facial, glosso-
ssure and its contents. Surg Radiol Anat 21:181185. pharyngeal, vagus, accessory and hypoglossal nerves (authors
Gray H, Williams PL. 1989a. Cranial and intracranial veins. In: Gray transl)]. Arch Otorhinolaryngol 231:169.
H, editor. Grays Anatomy. 37th Ed. Edinburgh; New York: C. Liv- Loughner BA, Larkin LH, Mahan PE. 1990. Nerve entrapment in the
ingstone. p 798805. lateral pterygoid muscle. Oral Surg Oral Med Oral Pathol 69:299
Gray H, Williams PL. 1989b. The cranial nerves. In: Gray H, editor. 306.
Grays Anatomy. 37th Ed. Edinburgh; New York: C. Livingstone. Martins C, Costa E Silva IE, Campero A, Yasuda A, Aguiar LR,
Hollinshead WH. 1982a. The cranium. In: Hollinshead WH, editor. Tatagiba M, Rhoton A Jr. 2011. Microsurgical anatomy of the
Anatomy for Surgeons. 3rd Ed. Philadelphia [etc.]: Lippincott. p orbit: The rule of seven. Anat Res Int 2011:468727.
6068. Moore KL, Dalley AF. 1999. Clinically Oriented Anatomy, 4th Ed. Bal-
Hollinshead WH. 1982b. The jaws palate, and tongue. In: Hollins- timore [etc.]: Lippincott Williams & Wilkins. p. 859861.
head WH, editor. Anatomy for Surgeons. 3rd Ed. Philadelphia Moretto EP, Silva GH, Toledo Filho JL, Andreo JC, Navarro Rde L,
[etc.]: Lippincott. p 325385. Navarro JA. 2005. Surgical anatomy of the maxillary nerve in the
Hu KS, Kwak HH, Song WC, Kang HJ, Kim HC, Fontaine C, Kim HJ. zygomatic region. J Appl Oral Sci 13:167170.
2006. Branching patterns of the infraorbital nerve and topogra- Morton AL, Khan A. 1991. Internal maxillary artery variability in the
phy within the infraorbital space. J Craniofac Surg 17:1111 pterygopalatine fossa. Otolaryngol Head Neck Surg 104:204209.
1115. Natori Y, Rhoton AL Jr. 1995. Microsurgical anatomy of the superior
Hwang K, Kim YJ, Chung IH, Song YB. 2005. Course of the masse- orbital ssure. Neurosurgery 36:762775.
teric nerve in masseter muscle. J Craniofac Surg 16:197200. Osawa S, Rhoton AL Jr, Tanriover N, Shimizu S, Fujii K. 2008. Micro-
Izci Y, Gonul E. 2006. The microsurgical anatomy of the ciliary gan- surgical anatomy and surgical exposure of the petrous segment
glion and its clinical importance in orbital traumas: An anatomic of the internal carotid artery, Neurosurgery 63:210238; Discus-
study. Minim Invasive Neurosurg 49:156160. sion 239.
Janis JE, Hatef DA, Ducic I, Ahmad J, Wong C, Hoxworth RE, Osborn Peker S, Kurtkaya O, Uzu n I, Pamir MN. 2006. Microanatomy of the
T. 2010. Anatomy of the auriculotemporal nerve: Variations in its central myelin-peripheral myelin transition zone of the trigeminal
relationship to the supercial temporal artery and implications nerve, Neurosurgery 59:354359; Discussion 354359.
88 Joo et al.

Pelletier VA, Poulos DA, Lende RA. 1974. Functional localization in Shankland WE 2nd. 2001c. The trigeminal nerve. Part IV: the man-
the trigeminal root. J Neurosurg 40:504513. dibular division, Cranio 19:153161.
Piagkou MN, Demesticha T, Piagkos G, Androutsos G, Skandalakis P. Shi X, Han H, Zhao J, Zhou C. 2007. Microsurgical anatomy of the
2011. Mandibular nerve entrapment in the infratemporal fossa. superior orbital ssure. Clin Anat 20:362366.
Surg Radiol Anat 33:291299. Shinohara H, Mataga I, Kageyama I. 2010. Discussion of clinical
Pogrel MA, Renaut A, Schmidt B, Ammar A. 1995. The relationship anatomy of the lingual nerves. Okajimas Folia Anat Jpn 87:97
of the lingual nerve to the mandibular third molar region: An 102.
anatomic study. J Oral Maxillofac Surg 53:11781181. Simoes S. 1993. An anatomical study of the laterotrigeminal venous
Rahman M, Richter EO, Osawa S, Rhoton AL Jr. 2009. Anatomic system. Ann Anat 175:115118.
study of the infraorbital foramen for radiofrequency neurotomy Taptas JN. 1982. The so-called cavernous sinus: A review of the
of the infraorbital nerve, Neurosurgery 64:423427; Discussion controversy and its implications for neurosurgeons. Neurosur-
427428. gery 11:712717.
Rhoton AL. 2003a. The cavernous sinus, the cavernous venous plexus, Totonchi A, Pashmini N, Guyuron B. 2005. The zygomaticotemporal
and the carotid collar. In: Rhoton AL, Congress of Neurological Sur- branch of the trigeminal nerve: An anatomical study. Plast
geons, editors. Rhoton Cranial Anatomy and Surgical Approaches. Reconstr Surg 115:273277.
Philadelphia: Lippincott Williams & Wilkins. p 403438. Tubbs RS, Hill M, May WR, Middlebrooks E, Kominek SZ, Marchase
Rhoton AL. 2003b. The orbit. In: Rhoton AL, Congress of Neurologi- N, Shoja MM, Loukas M, Oakes WJ. 2008. Does the maxillary
cal Surgeons, editors. Rhoton Cranial Anatomy and Surgical division of the trigeminal nerve traverse the cavernous sinus? An
Approaches. Philadelphia: Lippincott Williams & Wilkins. p 331 anatomical study and review of the literature. Surg Radiol Anat
362. 30:3740.
Rhoton AL Jr. 2000. The cerebellopontine angle and posterior fossa Tubbs RS, Johnson PC, Loukas M, Shoja MM, Cohen-Gadol AA. 2010.
cranial nerves by the retrosigmoid approach. Neurosurgery 47: Anatomical landmarks for localizing the buccal branch of the tri-
S93S129. geminal nerve on the face. Surg Radiol Anat 32:933935.
Rusu MC, Pop F, Curca  GC, Podoleanu L, Voinea LM. 2009. The pter- Vrionis FD, Cano WG, Heilman CB. 1996. Microsurgical anatomy of
ygopalatine ganglion in humans: A morphological study. Ann the infratemporal fossa as viewed laterally and superiorly, Neuro-
Anat 191:196202. surgery 39:777785; discussion 776785.
Sabanci PA, Batay F, Civelek E, Al Mefty O, Husain M, Abdulrauf SI, Wentges RT. 1975. Surgical anatomy of the pterygopalatine fossa. J
Karasu A. 2011. Meckels cave, World Neurosurg 76:335341; Laryngol Otol 89:3545.
Discussion 266337. Yoshida K, Kawase T. 1999. Trigeminal neurinomas extending into
Saunders RL, Sachs E Jr. 1970. Relation of the accessory rootlets of multiple fossae: surgical methods and review of the literature. J
the trigeminal nerve to its motor root. A microsurgical autopsy Neurosurg 91:202211.
study. J Neurosurg 33:317324. Yousry I, Moriggl B, Holtmannspoetter M, Schmid UD, Naidich TP,
Schmidt BL, Pogrel MA, Necoechea M, Kearns G. 1998. The distribu- Yousry TA. 2004. Detailed anatomy of the motor and sensory
tion of the auriculotemporal nerve around the temporomandibu- roots of the trigeminal nerve and their neurovascular relation-
lar joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86: ships: a magnetic resonance imaging study. J Neurosurg 101:
165168. 427434.
Shankland WE 2nd. 2000. The trigeminal nerve. Part I: An overview. Youssef S, Kim EY, Aziz KM, Hemida S, Keller JT, van Loveren HR.
Cranio 18:238248. 2006. The subtemporal interdural approach to dumbbell-shaped
Shankland WE 2nd. 2001a. The trigeminal nerve. Part II: the trigeminal schwannomas: Cadaveric prosection, Neurosurgery
ophthalmic division, Cranio 19:812. 59:ONS270ONS277; discussion ONS277ONS278.
Shankland WE 2nd. 2001b. The trigeminal nerve. Part III: The Zoud K, Doran GA. 1993. Microsurgical anatomy of the inferior alve-
maxillary division, Cranio 19:7883. olar neurovascular plexus. Surg Radiol Anat 15:175179.

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