Download OMFS Lecture

Head & Neck Anatomical
Dissection Course 8/14/07
Jason E. Portnof DMD, MD
Chief Resident
Division of Dentistry, Oral & Maxillofacial
Surgery
New York Presbyterian Hospital
Weill Cornell Medical College
Muscles of Facial Expression
Muscles of Mouth, Lips, Cheek
Circumoral Muscles
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Orbicularis oris
Sphincter of oral aperture.
Dilator Muscles
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Levator labii superioris alaque nasi
Elevator of upper lip and alae of nose.
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Mentalis
Raises skin of chin.
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Buccinator
Aids mastication by pressing the cheeks against the molar
teeth during chewing.
Muscles of Mouth, Lips, Cheek
Depressor anguli oris
Levator anguli oris
Zygomaticus major
Zygomaticus minor
Levator labii superioris
Deprssor labii inferioris
Risorius
Platysma
Lymphatic Drainage of Lips
Lymph from upper lip and lateral parts of
lower lip drains to submandibular LN
Lymph from middle part of lower lip drains
to submental LN
Facial Nerve
Main trunk emerges from Skull Base at Stylomastoid
Foramen.
Enters the Parotid Gland.
2 trunks emerge from the parotid and radiate anteriorly.
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Temporofacial
Cervicalfacial
5 Terminal Branches
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Temporal
Zygomatic
Buccal
Marginal Mandibular
Cervical
Oral Cavity
Boundaries:
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Extends from lips anteriorly to palatoglossal folds
posteriorly (i.e., anterior to oropharynx).
Structures:
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Tongue
Teeth
Alveolar Bone
The oral vestibule is the space between the
cheeks and the teeth/gums.
Pharynx
Nasopharynx
Oropharynx
Hypopharynx (Laryngopharynx)
Pharyngeal Wall
5 Layers
Mucosa
Submucosa
Pharyngobasilar fascia
Muscular Layer
Buccopharyngeal fascia
Oropharynx
Boundaries of the oropharynx:
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Anteriorly: junction of the hard and soft palate
and circumvallate papillae of the tongue base.
Superiorly: imaginary line drawn from the hard
palate to the posterior oropharyngeal wall.
Inferiorly: pharyngoepiglottic folds.
Structures:
Tonsils, tonsillar fossa, tonsillar pillars, tongue
base and a portion of the posterior pharyngeal
wall.
Oropharynx Structures
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Folds (or faucial pillars)
Folds in the mucous lining of the oral
cavity formed by the underlying
palatoglossal and palatopharyngeal
muscles.
Palatoglossal folds run from the wall of
the oral cavity to the approximate
junction of the posterior 1/3 and anterior
2/3 of the tongue.
Oropharynx Structures
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Tonsils
Palatine (faucial) tonsils are located immediately posterior to
the palatoglossal folds and anterior to the palatopharyngeal
folds; inferior to the soft palate and superior to the tongue; and
medial to the superior constrictors, the styloglossus, and the
glossopharyngeal nerve (IX).
Nasopharyngeal (pharyngeal) tonsils are located on the
posterior aspect of the nasopharynx.
„ When enlarged these are referred to as the adenoids.
Lingual tonsils are lymphoid tissue in the tongue.
„ Continuous with the inferior pole of the palatine tonsil.
Nasopharynx
Soft palate separates
nasopharynx from
oropharynx.
Adenoids
Pharyngeal tonsils, nasopharyngeal tonsils
Mass of lymphoid tissue situated in the roof of
the nasopharynx
Palate
Vasculature: (Bilateral)
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Greater palatine artery
Branch of descending palatine artery
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Lesser palatine artery
Branch of descending palatine artery
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Ascending palatine artery
Branch of Facial Artery
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Veins of palate
Tributaries of pterygoid venous plexus
Innervation of Palate
Sensory nerves of palate are branches of
pterygopalatine ganglion
Greater palatine nerve supplies gingiva,
mucous membrane, and glands of hard
palate
Nasopalatine nerve supplies mucous
membrane of anterior part of hard palate
Lesser palatine nerves supply soft palate
Hard Palate
Palatine processes of
maxilla and horizontal
plates of the palatine bones.
Periosteum of the hard
palate is continuous into the
soft palate (palatine
aponeurosis), and is the
insertion site of the palatal
muscles.
Landmarks
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Incisive Foramen
Greater Palatine Foramen
Lesser Palatine Foramen
Soft Palate
Muscle
Action
Innervation
Levator veli palatini
elevates the soft palate
Pharyngeal Plexus
Tensor veli palatini
Tenses the palate,
opens mouth of auditory
tube
Mandibular Nerve V3
(medial pterygoid nerve)
Palatoglossus
Elevates posterior
Pharyngeal Plexus
tongue, draws soft palate
into tongue
Palatopharyngeus
Tenses soft palate. Pulls Pharyngeal Plexus
the pharynx superiorly,
anteriorly, medially
Musculus Uvulae
Shortens uvula, pulls it
superiorly
Pharyngeal Plexus
Trigeminal Nerve
CN 5 Trigeminal Nerve
Originates in Pons.
Both motor and sensory nerve.
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Ophthalmic and maxillary nerves are purely sensory.
The mandibular nerve has both sensory and motor
functions.
Three large trunks originate from the semilunar
ganglion (Gasserian ganglion).
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Exit Skull at 3 different foramina
V1: Superior Orbital Fissure
V2: Foramen Rotundum
V3: Foramen Ovale
Trigeminal Nerve Branches
Opthalmic Nerve
(V1)
Maxillary Nerve (V2)
Mandibular Nerve
(V3)
Nasociliary nerve
Supraorbital nerve
Lacrimal nerve
Frontal nerve
Supratrochlear nerve
Infratrochlear nerve
Zygomatic nerve
Posterior superior
alveolar nerve
Middle superior
alveolar nerve
Anterior superior
alveolar nerve
Infraorbital nerve
Greater Palatine
nerve
Nasopalatine nerve
Auriculotemporal
nerve
Lingual nerve
Buccal nerve
Inferior alveolar
nerve
(Mental nerve)
CN V Dermatome Distribution
Maxilla
Each half of the fused
maxilla consists of:
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The body of maxilla
Four processes
Zygomatic process
Frontal process
Alveolar process
Palatine process
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Infraorbital foramen
Mandible
Condyle
Sigmoid Notch
Ramus
Angle
External Oblique
Ridge
Symphysis
Mental Foramen
Mandible
Sphenomandibular
Ligament
Stylomandibular
Ligament
Muscle Attachments of the
Mandible
Muscles of Mastication
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Temporalis
Masseter
Lateral Pterygoid
Medial Pterygoid
Suprahyoid Muscles
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Geniohyoid
Mylohyoid
Digastric (anterior belly)
Stylohyoid
Genioglossus
Muscle
Origin
Insertion
Function
Floor of temporal fossa,
deep surface of temporal
fascia.
Coroniod process, anterior
border of mandibular
ramus.
Elevates and retrudes
mandible.
Masseter
Superficial portionanterior 2/3 of inferior
border of zygomatic arch.
Deep portion- medial
surface of zygomatic arch.
Lateral surface of ramus,
coronoid process, and
angle of mandible.
Elevates, protrudes, and
retrudes mandible.
Lateral Pterygoid
Superior headinfratemporal surface of
sphenoid greater wing.
Inferior head- lateral
surface of lateral pterygoid
plate.
Anterior portion of
condylar neck and TMJ
capsule.
Protrusion of mandible.
Lateral movements of
mandible.
Medial Pterygoid
Deep head- Medial
surface of lateral pterygoid
plate; pyramidal process
of palatine bone.
Superficial head- maxillary
tuberosity.
Medial surface of ramus,
inferior to mandibular
foramen.
Protrudes and elevates
mandible. Lateral
movements of mandible
Temporalis
Muscle
Origin
Insertion
Function
Geniohyoid
Inferior genial
tubercle on inner
surface of
mandibular
symphysis.
Body hyoid bone.
Elevates tongue,
FOM, and hyoid.
Mylohyoid
Line from last molar
to mandibular
symphysis.
(mylohyoid line)
Raphe and body of
hyoid bone.
Elevates base of
hyoid bone. Raises
floor of mouth and
tongue.
Posterior bellymastoid notch
(temporal bone).
Anterior bellydigastric fossa
(mandible) .
Intermediate tendon
attached to hyoid
bone by fibrous
loop.
Depresses
mandible, Elevates
the hyoid bone.
Posterior border of
the styloid process.
Body of hyoid bone.
Elevates base of
tongue and hyoid
bone.
Digastric
Stylohyoid
Accessory Muscles to the Muscles
of Mastication
Platysma
Buccinator
Posterior neck musculature
Sternocleidomastoid
Trapezius
Intrinsic neck muscles
Temporomandibular Joint (TMJ)
TMJ
Classification:
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Ginglymoarthrodial Joint
Translational (gliding) movement
Rotational (hinging) movement
Synovial Joint
TMJ Anatomy
Articulation between the condyle of the mandible and the
squamous portion of the temporal bone (TMJ fossa).
Articular disc lies between condyle and fossa.
Condyles
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Elliptically shaped.
Long axis oriented mediolaterally.
Articular Surface of Temporal Bone
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Functional aspect of TMJ.
Dense fibrous connective tissue.
Concave : Articular fossa (Glenoid Fossa, Mandibular Fossa)
Convex : Articular eminence (tubercle)
Articular Disc
Dense fibrocartilagenous connective tissue.
Avascular and aneural.
Nutrition of chondrocytes with the movement of synovial fluid is essential for
maintenance of structure and function.
Biconcave structure is a three dimensional space filler between the two
convex surfaces of the condyle and articular eminence.
Separates joint into inferior and superior joint spaces.
Varies in thickness.
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Intermediate zone- thin (center of disc)
Anterior and Posterior Bands- thick
Posterior band is thicker and is attached to retrodiscal tissues (bilaminar zone, posterior
attachment).
Anterior band is attached to the capsular ligament, the lateral pterygoid muscle, and the
condyle.
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Retrodiscal Tissues
Loose connective tissues.
Vascular and Innervated.
TMJ Disorders
TMJ Reconstruction
Infratemporal Fossa
Boundaries
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Laterally: Ramus of Mandible
Medially: Lateral Pterygoid Plate
Anteriorly: Posterior Aspect of Maxilla
Posteriorly: Tympanic Plate and the Mastoid
and Styloid Processes of the Temporal Bone
Superiorly: Inferior Surface of the Greater
Wing of the Sphenoid Bone
Inferiorly: Where the Medial Pterygoid Muscle
Attaches to the Mandibular Angle
Infratemporal Fossa
Contents:
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Inferior part of the temporal muscle
Lateral and medial pterygoid muscles
Maxillary artery
Pterygoid venous plexus
Mandibular, Inferior alveolar, lingual, buccal,
and chorda tympani nerves, and otic ganglion
Arteries of Face
Artery
Origin
Course
Distribution
Facial
External Carotid
Artery
Ascends deep to
submandibular
gland, rounds
around inferior
border of
mandible and
enters face
Muscles of facial
expression and face
Inferior Labial
Facial artery near
angle of mouth
Runs medially in
lower lip
Lower lip and chin
Superior Labial
Facial artery near
angle of mouth
Runs medially in
upper lip
Upper lip and ala
and septum of nose
Lateral nasal
Facial artery as it
ascends
alongside nose
Passes to ala of
nose
Skin on ala and
dorsum of nose
Angular
Terminal branch
of facial artery
Passes to medial
angle (canthus) of
eye
Superior part of
cheek and lower
eyelid
Arteries of Face
Artery
Origin
Course
Superficial
temporal
Smaller terminal
Ascends anterior
branch of external to ear to temporal
carotid artery
region and ends
in scalp
Transverse facial
Superficial
temporal artery
within parotid
gland
Mental
Terminal branch
Emerges from
of Inferior alveolar mental foramen
artery
and passes to
chin
Crosses face
superficial to
masseter and
inferior to
zygomatic arch
Distribution
Facial muscles
and skin of frontal
and temporal
regions
Parotid gland and
duct, mauscles
and skin of face
Facial muscles
and skin of chin
Maxillary Artery
Arises from External Carotid Artery
Arises posterior to neck of mandible
Passes anteriorly (deep to neck of
condyle)- 1st part
Passes superficial or deep to the lateral
pterygoid muscle- 2nd part
Passes through pterygomaxillary fissure to
enter infratemporal fossa- 3rd part
1st (Mandibular) Part
Deep auricular artery to external acoustic
meatus
Anterior tympanic artery to tympanic
membrane
Middle meningeal artery to dura mater and
calvaria
Accessory meningeal arteries to the cranial
cavity
Inferior alveolar artery to mandible, gingiva,
teeth
2nd (Pterygoid Part)
Deep temporal arteries, anterior and
posterior (supply temporal muscle)
Pterygoid arteries (supply pterygoid
muscles)
Masseteric artery (supplies deep surface
of masseter muscle)
Buccal artery (supplies buccinator
muscle)
3rd (Pterygopalatine) Part
Posterior superior alveolar artery
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supplies maxillary molar and premolar teeth, lining of maxillary sinus,
gingiva
Infraorbital artery
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supplies inferior eyelid, lacrimal sac, side of nose, superior lip
Descending palatine artery
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supplies maxillary gingiva, palatine glands, mucous membrane of roof of
mouth
Artery of pterygoid canal
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supplies superior part of pharynx, pharyngotympanic tube, tympanic
cavity
Pharyngeal artery
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supplies roof of pharynx, sphenoidal sinus, inferior part of
pharyngotympanic tube
Sphenopalatine artery
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supplies lateral nasal wall, nasal septum, paranasal sinuses
Veins of Face
Vein
Origin
Termination
Area Drained
Facial
Continuation
of angular vein
past inferior
margin of orbit
Internal jugular vein
opposite or inferior to
hyoid bone
Anterior scalp and
forehead, eyelids, external
nose, anterior cheek, lips,
chin, submandibular gland
Deep facial
Pterygoid
venous plexus
Enters posterior
aspect of facial vein
Infratemporal fossa (most
areas supplied by maxilary
artery)
Veins of Face
Superficial
temporal
Begins from
a widespread
plexus of
veins on side
of scalp and
along the
zygomatic
arch
Joins the maxillary Side of scalp, superficial
vein posterior to the aspect of temporal
muscle, external ear
neck of the
mandible to form
the retromandibular
vein
Retromandibular
Formed
anterior to
the ear by
union of
superficial
temporal and
maxillary
veins
Unites with
posterior auricular
vein to form
external jugular
vein
Parotid gland and
masseter muscle
Salivary Glands
Parotid Gland
Sublingual Gland
Submandibular Gland
Parotid Gland
Stensen’s Duct
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Pierces the buccal fat,
buccopharyngeal
fascia and buccinator
muscle.
Opens into the
vestibule of the mouth
opposite the maxillary
2nd molar tooth.
Floor of Mouth
Sublingual Salivary Glands
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Sublingual folds (plica
sublingualis).
Run anteroposterior
alongside the frenulum, one
per side, converging just
anterior to the root of the
frenulum.
Overly the sublingual
salivary glands from which
numerous ducts travel and
open onto the top of each
fold.
Each gland does not have a
single duct, but many which
open directly into the oral
cavity.
Floor Of Mouth
Submandibular Gland
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Duct emanates from the
posterior aspect of gland and
travels deep to mylohyoid on
the superficial surface of the
hyoglossus and genioglossus
muscles.
At the anterior most extent of
each sublingual fold, the
opening for the duct of the
submandibular salivary gland.
(Wharton’s Duct)
Buccal Fat Pad
Encapsuled mass of fat in the cheek on the
outer side of the buccinator muscle
Found in the space between the masseter
muscle and the external surface of the
buccinator
Pterygomandibular Raphe
Tendinous band of the buccopharyngeal fascia
Attached to:
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Hamulus of the medial pterygoid plate.
Posterior end of the mylohyoid line of the mandible.
Boundaries:
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medial surface is covered by the mucous membrane
of the mouth.
lateral surface is separated from the ramus of the
mandible by adipose tissue.
posterior border attaches to the superior pharyngeal
constrictor muscle.
anterior border attaches to buccinator.
Tongue
Surface Anatomy Tongue
Sulcus terminalis
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V-shaped line (with the point
facing posteriorly) that
separates the anterior 2/3 and
posterior 1/3 of the tongue.
At the point, a shallow pit
named the foramen cecum is
present (original location of
thyroid diverticulum).
Located posterior to a row of
vallate papillae.
Lingual Tonsils
Rounded masses of lymphatic tissue that cover
the posterior region of the tongue.
Located on the dorsal surface at the base of the
tongue.
Innervation Tongue
Anterior 2/3
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Lingual Nerve (V3)- general sensation
Chorda typmani (CN 7)- taste
Posterior 1/3
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Lingual branch glossopharyngeal nerve (CN
IX)- general sensation, taste
Lingual branch facial nerve- taste
Internal laryngeal branch Vagus- general
sensation, taste
Motor Innervation Tongue
Palatoglossus- pharyngeal plexus (CN XI,
CNX)
All other muscles- CN XII (hypoglossal)
Extrinsic Muscles of Tongue
Genioglossus
Hyoglossus
Styloglossus
Palatoglossus
Genioglossus Muscle
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Origin: Superior part mental spine of
mandible.
Insertion: Dorsum of tongue, body of hyoid
bone.
Innervation: CN 12 (Hypoglossal Nerve).
Depresses tongue, posterior part pulls tongue
anteriorly for protrusion
Hyoglossus Muscle
Origin: Body and
greater horn of hyoid
Insertion: Side and
inferior aspect of
tongue
Innervation: CN XII
Depresses and
retracts tongue
Styloglossus Muscle
Origin: Styloid process and stylohyoid
ligament
Insertion: Side and inferior aspect of
tongue
Innervation: CN 12
Retracts tongue and draws it up to create
trough for swallowing
Palatoglossus Muscle
Origin: Palatine aponeurosis of soft palate
Insertion: Side of tongue
Innervation: Cranial root of CN XI via
pharyngeal branch of CN X and
pharyngeal plexus
Elevates posterior part of tongue
Intrinsic Muscles Tongue
Superior Longitudinal
Inferior Longitudinal
Transverse
Vertical
Tongue Vasculature
Lingual artery (from external carotid artery)
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Dorsal lingual arteries
Deep lingual artery
Sublingual artery
All veins terminate in the Internal Jugular
Vein
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Dorsal lingual veins
Deep lingual veins (ranine veins)
Sublingual vein
Lymph Drainage from Tongue
Lymph from posterior 1/3Æ Superior deep
cervical LN
Lymph from medial part of anterior 2/3 Æ
Inferior deep cervical LN
Lymph from lateral anterior 2/3 Æ
submandibular LN
ApexÆ submental LN
Posterior 1/3 & area near midline Æ drain
bilaterally
Periodontal Anatomy
Periodontium
Gingiva
Periodontal Ligament (PDL)
Cementum
Alveolar and supporting bone
Healthy Gingiva
Evaluate Color, Contour, Tone and Consistency
of Gingival Tissue
Gingiva
Masticatory mucosa which cover the alveolar process and surround
the cervical portion of teeth.
Composed of connective tissue and epithelium.
Epithelium can be divided into three histological distinct areas:
Oral epithelium
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Continuous with epithelial lining of the attached gingiva.
Composed of keratinized stratified squamous epithelium.
Sulcular epithelium
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Non-keratinized
Junctional epithelium
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Attached to the tooth by hemidesmosomes.
Non-keratinized.
Larger cells with increased intercellular spaces.
Gingival Fibers
Composed of type I collagen.
Support the gingiva and attach it to the tooth and
alveolar bone.
Gingival fibers are continuous with the
periodontal ligament.
Designated by their orientation.
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Dentogingival fibers
Dentoperiosteal fibers
Circular fibers
Alveologingival fibers
Transseptal fibers
Principal Fibers of the Periodontal
Ligament (PDL)
Bundles of collagen fibers grouped
according to the direction they extend from
the cementum of the root to the alveolar
bone.
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Horizontal Fibers
Alveolar Crest Fibers
Oblique Fibers
Apical Fibers
Interradicular Fibers
Tooth Anatomy
Universal/National System for
Permanent (Adult) Dentition (1-32)
Maxillary Arch (1-16)
Mandibular Arch (17-32)
3 Molars, 2 Premolars, 1
Canine, 1 Lateral Incisor,
1 Central Incisor in each
arch quadrant
The Universal/National System for
the Primary (Baby) Dentition
A
T
Upper case letters A through T
No Premolars in the Primary Dentition
Sequence of Eruption
Deciduous central/ lateral incisiors (6-9 months)
First deciduous molar (12-14 months)
Deciduous canine (16-18 months)
Second deciduous molar (24-30 months
First permanent molar, central/ lateral incisors
(6-9 years)
Permanent canine, first/ second premolars,
second molar (10-13 years)
Permanent third molar (17-21 years)
Curve of Spee
Curvature of the
mandibular occlusal
plane beginning at the
tip of the lower cuspid
and following the
buccal cusps of the
posterior teeth,
continuing to the
terminal molar.
Anterior-posterior
curve
Curve of Wilson
Lateral curve
Occlusion
Combination of Curve of Spee and Curve
of Wilson create the Occlusal Plane
Centric Relation Position
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Anatomic relationship of the TMJ joint.
Muscles of Mastication are at rest.
Occlusion
Angle Classification of Occlusion
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Class I—patient’s profile
is characterized as
normal.
Class II—patient’s profile
is deficient in chin length
and characterized as a
retruded (retrognathic)
profile.
Class III—patient’s
profile is excessive in
chin length and
characterized as
protruded (prognathic)
profile.
Overjet / Overbite: Horizontal and
Vertical Overlap
Occlusal Surface of Teeth
Canine= Cuspid
Premolar= Bicuspid
Normal Cusp Relationship of
Posterior Teeth
Mesiofacial cusp of
the maxillary first
molar occludes in the
facial groove of the
mandibular first molar
Orthognathic Surgery
Jaw Realignment and
Correction of Facial
Profile
Maxillary (oneÆ
multiple piece
osteotomies)
Mandibular
osteotomies
Orthognathic Surgery
Cephalometric Analysis
Cepahalometric Analysis
Lefort 1 Osteotomy
BSR
Mandibular ramus sagittal split osteotomy is the
most common technique used for mandibular
advancement
BSR
Bilateral Sagittal Split Ramusotomy
Vertical Ramus Osteotomy
Vertical ramus osteotomy can be used to set the
mandible posteriorly.
Genioplasty
Anterior Mandibular Horizontal Osteotomy
Facial Trauma
Facial Trauma
R Zygomatic Arch Fracture
Distribution of Mandible Fractures
Mandible Fracture
Tx Mandible Fx
ORIF Mandible Fx
LeFort Fractures
Wisdom Teeth
Wisdom Teeth (3rd Molars)
Extraction of Mandibular 3rd Molar
Tooth
Extraction of Mandibular 3rd Molar
Tooth
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