Download Oral cavity

Head & Neck Surgery Course
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Oral cavity: surgicalm
anatomy
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Dr Pierfrancesco PELLICCIA
Pr Benjamin LALLEMANT
Service ORL et CMF
CHU de Nîmes
CH de Arles
Introduction
Schematic representation of oral cavity and floor of mouth
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A: philtrum; B: upper labial frenulum; C: opening of Stensen's duct; D: labial commissure; E: hard palate; F:
soft palate; G: intermaxillary commissure; H: base of tongue; I: lateral border of tongue, dorsal view; J:
tip of tongue, dorsal view; K: tip of tongue, ventral view; L: lateral border of tongue, ventral view; M:
ventral surface of tongue; N: lingual frenulum; O: floor of mouth; P: opening of Wharton's duct; Q:
vestibular gingiva; R: vestibule.
Introduction
Mucosal features of oral cavity
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Introduction
Coronal section
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Introduction
Physiology
Functions
• Speech
• Mastication
• bolus preparation and
initiation of deglutition
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Oral cavity: anatomy
Boundaries
• Anteriorly:
– Vermilions (superiorly and
inferiorly)
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• Posteriorly: the oral cavity is
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separated from the oropharynx
by
– the anterior tonsillar pillars
– circumvallate papillae
(inferiorly)
– junction of hard and soft
palate (superiorly)
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Oral cavity: anatomy
Skeleton
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• Mandible
• Maxilla
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• Palatine bone
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Oral cavity: anatomy
Skeleton
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Oral cavity: anatomy
Skeleton
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Oral cavity: anatomy
Muscles
• Masticatory muscles
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Temporal
Masseter
Internal pterygoid
External pterygoid
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Muscles of facial
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expression
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Oral cavity: arterial supply
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Oral cavity: arterial supply
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Oral cavity: venous supply
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Oral cavity: innervation
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Greater palatine nerve (V2)
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Lingual nerve (V3 and VII)
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XII CN
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Inferior alveolar
nerve (V3)
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Posterior, midldle and anterior superior
alveolar nerve (V2)
Oral cavity: innervation
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Oral cavity: innervation
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Oral cavity: innervation
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Oral cavity: innervation
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Oral cavity: lymphatics
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1st echelon nodes:ww
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level I,II,III
• Then IV, V
• Skip metastasis!
Sites of oral cavity
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lips
alveolar ridges
buccal mucosa
retromolar trigone
hard palate
floor of mouth
mobile tongue
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Tongue: anatomy
•The sulcus terminalis
divide the anterior
and posterior tongue
•Tongue base ends at
the vallecula
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•Foramen cecumarea(where the
thyroid descends)
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Tongue: muscles
•There are 8 muscles of
the tongue
•They are classified as
intrinsic and extrinsic
muscles
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Tongue: muscles
There are 4 paired
intrinsic muscles of the
tongue
 Superior
Longitudinal
 Inferior longitudinal
 Verticalis
 Transversus muscle
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Tongue: muscles
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Function of the intrinsic muscles
Inferior and superior longitudinal
muscles - Move tip up and down
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Transverse muscle -Narrows and
lengthens the tongue
Vertical Muscle - Flattens and
depresses the tongue
Tongue: muscles
The 4 extrinsic muscles
are
 Genioglossus-from the
mandible
 Hyoglossus- from the
hyoid bone
 Styloglossus- from the
styloid process
 Palatoglossus- from the
palatine aponeurosis
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Tongue: muscles
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Function of the extrinsic muscles
Genioglossus- protrusion of
tongue apex from the mouth
Hyoglossus- depression of the
tongue
Styloglossus- elevates and retracts
the tongue
Palatoglossus- elevates and
retracts the tongue
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Tongue: arterial supply
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•lingual artery
•Other contributors include
the ascending palatine and
tonsillar branch of the facial
artery
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Tongue: venous supply
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•lingual vein
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Tongue: innervation
Sensory nerves
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Motor innervation
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Tongue: innervation
Sensory nerves
Lingual branch of V2-General sensation
for the anterior two thirds of tongue
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Chorda tympani of CN VII- taste for
anterior 2/3
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Lingual branch of CN IX- General
sensation and taste for posterior 1/3
Superior laryngeal CN X- root of tongue
and lingual base sensation.
Tongue: innervation
Motor innervation
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All tongue muscles are innervated by
XII except the palatoglossusinnervated by X
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Hard palate: anatomy
• The palate forms the roof
of the mouth and
intervenes between the
nasal and oral cavities.
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• It consists of the palatine
process of the maxilla,
the horizontal plates of
the palatine bone.
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Hard palate: anatomy
• Three foramina open on
the oral aspect of the
hard palate
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Foramina that open on the oral
aspect of the hard palate
Incisive Fossa
– Slight depression posterior
to central incisor teeth
– Nasopalatine nerve
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Greater palatine foramina
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– Medial to 3rd Molar
– Greater palatine vessels and
nerve
Lesser palatine foramina
– Lesser Palatine nerves and
vessels to soft palate
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Hard palate: arterial supply
Greater palatine artery
• branch of the third part of the
maxillary artery
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• it descends with its
accompanying nerve in the
palatine canal.
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Superior Alveolar Arteries
• terminal branches of the
internal maxillary artery
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Hard palate: arterial supply
• The greater palatine emerges on
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the hard palate from the greater
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palatine foramen
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• runs forward in a groove on the
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inferior surface of the bony palate
almost to the incisor teeth
• supplies the gums and the
mucosa and glands of the hard
palate.
Hard palate: arterial supply
• The superior alveolar
arteries (anterior, middle,
posterior) provide blood
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supply to the maxillary
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gingiva, alveolar ridge, and
dentition
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Hard palate: venous supply
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• The venous drainage is to
the pterygoid plexus
and subsequently to the
internal jugular venous
system.
Hard palate: innervation
• The nasopalatine
nerves
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• Greater Palatine Nerves
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Hard palate: innervation
• The nasopalatine
nerves
– branches of V2
– They enter the palate at
the incisive foramen
– they supply the anterior
part of the hard palate
behind the incisor teeth.
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Hard palate: innervation
• Greater Palatine Nerves
– Greater (and Lesser) Palatine run
through the palatine canal and exit
at the Great and Lesser Palatine
Foramens, respectively.
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Hard palate: innervation
• Greater Palatine Nerves
– Parasympathetic
postganglionic secretomotor
fibres from the
pterygopalatine ganglion run
with the nerves to supply the
palatine mucous glands.
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Perineural Spread
• Tumors spreading by
perineural extension can
be discovered by
radiographic enlargement
of the palatine foramina
or widening of the
palatine canals or the
foramen rotundum.
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Upper Alveolar Ridge
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• The upper alveolar ridge
consists of mucosa
overlying the alveolar
process of the maxilla and
extends from the
gingivobuccal sulcus to the
junction of the hard palate
medially.
Inferior Alveolar Ridge
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• The inferior alveolar ridge consists of mucosa overlying the alveolar
process of the mandible and extends from the gingivobuccal sulcus
to the junction of the floor of the mouth.
Floor of the mouth (FOM):
anatomy
• FOM extends from the
inferior alveolar ridge to the
anterior tongue
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Floor of the mouth (FOM):
anatomy
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Floor of the mouth (FOM):
anatomy
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Floor of the mouth (FOM):
anatomy
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Floor of the mouth (FOM):
anatomy
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Floor of the mouth (FOM):
anatomy
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Lips and buccal mucosa: anatomy
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Lips and buccal mucosa: anatomy
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Retromolar trigone: anatomy
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Head & Neck Surgery Course
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Oral cavity: surgical options
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and technique
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Dr Pierfrancesco PELLICCIA
Pr Benjamin LALLEMANT
Service ORL et CMF
CHU de Nîmes
CH de Arles
Surgical approaches to the oral
cavity
(a) Peroral
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(Mandibular
swing):
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(b) Mandibulotomy
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lower
lip-splitting incision or visor flap
(c) Lower cheek flap
(d) Visor flap (cervical
degloving)
(e) Upper cheek flap
a) Peroral es.fr
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Peroral partial glossectomy
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Peroral Pelvectomy
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Peroral approach to the palate
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Peroral resection of tumor of
the upper alveolus
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Marginal mandibulectomy-Pull Trough
operation (peroral)
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b) Mandibulotomy (Mandibular
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swing)
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Transmandubular resection of
oral/oropharyngeal cancer
• “Mandibular swing”
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• Midline lip splitting or visor flap
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• Mandibulotomy anteriorly, incise
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along floor of mouth to anterior
tonsillar pillar
• Identify hypoglossal nerve and
lingual nerve
• Divide styloglossus and
stylopharyngeus muscle
• Need tracheotomy
Partial glossectomy via lip split
mandibulotomy (Mandubular swing)
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c) Lower cheek flap
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Marginal mandibulectomy via lower
cheek flap (Pull Through operation)
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Marginal mandibulectomy via lower
cheek flap (Pull Through operation)
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Marginal mandibulectomy via lower
cheek flap (Pull Through operation)
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Segmental mandibulectomy –
Commando operation via lower cheek
flap
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Segmental mandibulectomy –
Commando operation via lower cheek
flap
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Segmental mandibulectomy –
Commando operation via lower cheek
flap
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d) Visor flap (cervical
degloving) fr
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Marginal mandibulectomy-Pull Trough
operation (visor flap)
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Anterior Segmental mandibulectomy
via visor flap
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Anterior Segmental mandibulectomy
via visor flap
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Partial glossectomy via visor flap
(Mandubular swing)
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e) Upper cheek flap
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Partial maxillectomy (upper cheek flap)
for tumor of hard palate/upper
alveolus
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f) Other approaches
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Midfacial degloving approach for
tumor of hard palate/upper alveolus
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Total glossectomy via mandibular
lingual release (Pull Through)
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Appendix: mandible
management
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Patterns of tumor invasion of the
mandible
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Patterns of tumor invasion of the
mandible
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Mandible management
• Patterns of tumor invasion of the mandible
dictate mandible management
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– Marginal mandibulectomy
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– Segmental mandibulectomy
Marginal mandibulectomy
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Marginal mandibulectomy
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Segmental mandibulectomy
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