2020

Head and Neck Anatomy

DR Jennings , DR SFERA
Aimee Matthews
WEEK 1: DR JENNINGS

STRUCTURE OF THE FACE AND SCALP

FACE AND SCALP

Development of the Head and Face

- Branchial arches begin to develop early in the 4th week as a result of neural crest cells migrating into the future head a
- By the end of week 4, there are 4 well defined pairs of arches that are separated by deep grooves, numbered

sequentially in a cranio-caudal direction

- Mandibular and hyoids arches (1st and 2nd) important for dentists
o 1st arch subdivides into two prominances – larger mandibular and smaller maxillary
- Stomodeum – primitive mouth
- Cartilages will develop into bone
- 1st arch – mandible
- 2nd arch – lesser cornu and stapes and styloid process
- 3rd arch – greater cornu
- 4th and 6th arches – laryngeal cartilages

- 1st arch muscles of mastication – innervated by Trigeminal Nerve (V)

- Only a few muscles innervated by V3 due to primarily sensory
 - 2nd arch muscles of facial expression – innervated by Facial Nerve (VII)

3rd arch muscle –

stylopharyngeus

- V2 – nasal cavity
- V3 – oral cavity
- VII – muscles of facial expression
- IX – pharynx
- X – larynx

Scalp

- Skin
- Connective tissue
 - Aponeurosis (flat tendon)
- Loose connective tissue
- Pericranium/periosteum

Aponeurosis - runs between frontal and occipital bellies of occipitofrontalis

Scalp proper (skin, connective tissue, aponeurosis) - moves relative to underlying pericranium due to the loose
connective tissue layer

Scalp Injuries – Bruising

- Loose connective tissue layer is where blood or pus can collect
- Danger area as infection can spread intra-cranially through emissary veins
- Emissary veins connect extracranial veins with intracranial veins, they lack valves
- Frontalis muscle inserts into skin and does not attach to bone – giving blood a
pathway beneath the muscle straight to the surface to show as bruising through
thin, delicate eyelids
- Occipitalis attaches to occipital and temporal bones – no spread of blood to skin
surface

Neurovasculature
Dermatomes (Sensory Innervation) of the Head and Neck
- Trigeminal Nerve – sensory pathway
- Only the mandibular branch (V3) has motor fibres running with it to innervate the muscles of mastication
- Small vagal branch (auricular) to the external acoustic meatus

Cutaneous Nerves of the Head

- Supraorbital nerve – through the supraorbital foramen
- Infraorbital nerve – through the infraorbital foramen
- Mental nerve – through mental foramen (of mandible)
- Auriculotemporal nerve – to the TMJ
Herpes Zoster/Shingles
- Shingles is caused by the chicken pox virus – Varicella zoster virus
- Usually rash and often painful blisters
- Fluid within the blisters bursts and spreads to viral particles
- Live in a particular part of the dorsal root or trigeminal ganglia
- Contained to one dermatome
- Once shingles subsides the virus remains in the patient in the appropriate
dermatome
- May reappear years later, especially when the immune system is compromised
- Incidence is age related - 3.4/1000 people in healthy population, 12/1000 in 65yrs+
Trigeminal Nerve

Only V3 carries motor supply

Supplies muscles of mastication and 4
smaller muscles

Masticatory Muscles

- Lateral pterygoid
- Medial pterygoid
- Temporalis
- Masseter
Blood vessels run with the nerves

Supratrochlear – medial

Supraorbital – lateral
Arteries of the Face and Scalp
- Run in dense connective tissue
- 5 each side – sourced from the internal and external carotids forming an anastomoses
o Supratrochlear (from internal carotid)
o Supraorbital (from internal carotid)
o Superficial temporal
o Posterior auricular
o Occipital
- Terminal branches of the external carotid – superficial temporal and maxillary

- Scalp wounds bleed profusely due to rich arterial supply by anastomoses

- Laceration through all 3 true scalp layers causes gaping because of the loss of tone in occipitofrontalis
muscle (and its cut connecting aponeurosis)
- Harder for the blood to clot due to the gaping, cut ends of the arteries are held open by the dense
connective tissue gaping

Veins of the Face and Scalp

- Follow arteries and have the same name
Thrombophlebitis of the Facial Vein

- Potential for clots/thrombi intracranially

- Movement possible between inside and outside of cranial cavity via superior and inferior ophthalmic veins
- No valves in the veins of the head – multidirectional flow (intra and extra cranial travel of infections etc.)
- Intracranial cavity is a closed – increased pressure (due to inflammation etc.) will have impacts

Lymphatic Drainage of the Face and Scalp

MUSCLES OF FACIAL EXPRESSION
STRUCTURE OF THE FACE
- Skin
- No real subcutaneous fascia
- Deep fascia splits into two to invest the parotid and attaches to bone
- Most muscles of facial expression originate in bone (or deep fascia) and insert directing into dermis of skin
(or onto other muscles)
- Muscles of facial expression in pairs
- Innervated by Facial Nerve (VII) - motor supply
- Exits skull through stylo-mastoid foramen
- 5 anterior branches pass through parotid gland

KRAISSL
- Aging causes loss of elasticity in skin
- Indication of the location of muscles based on skin folds
- Wound healing improves when incisions perpendicular to muscle fibres

FUNCTIONS OF FACIAL EXPRESSION MUSCLES

- Sphincters – orbicularis oculi, orbicularis oris
- Dilators – zygomaticus, levator labii sup, depressor anguli oris
- Others – platysma, occipitofrontalis

GROUPS OF FACIAL EXPRESSION MUSCLES

1. Scalp
2. Orbital
3. Nasal
4. Oral
5. Neck
6. Auricular

SCALP Group
Occipitofrontalis (Epicranius)
Frontal Belly/Frontalis
- O: Epicranial aponeurosis
- I: Eyebrow and root of nose
Occipital Belly/Occipitalis
- O: Occipital and temporal bone
- I: Epicranial aponeurosis
ORBITAL Group
Orbicularis oculi
- Sphincter
- Protects and moistens eye – assists flow of lacrimal fluid
- Fibres extend into eyelid and act to close eyelid
Orbital
- Fibres from orbital rim, nasal process of frontal bone and frontal process of maxilla
- Forcefully closes eye, wrinkling forehead eg. Squinting
Palpebral
- Fibres originate medially and insert laterally
- Gently closes eyelids eg. Blinking, sleep
Lacrimal
- Draws eyelids and lacrimal puncta medially so that capillary action may
drain lacrimal fluid from it

Corrugator Supercilli
- Deep to superior portion of orbicularis oculi
- O: frontal bone (supraorbital region)
- Passes superiorly and laterally
- I: skin tissue of the eyebrow

NASAL Group
Procerus
- Superficial to nasal bone (root of nose)
- Active when frowning
- O: Nasal bone and upper parts of nasal cartilages
- I: Skin between eyebrows

Nasalis
Transverse
- Compresses the nares
- O: Maxilla – fibres pass upward and medially
- I: Aponeurosis on the dorsum of the nose
Alar
- Draws alar cartilages downwards and laterally – opening the nares
- O: Maxilla
- I: Alar cartilage

Depressor Septi Nasi

- Widens nares
- O: Maxilla above central incisor
- I: Lower part of nasal septum

ORAL Group
Orbicularis oris
- Fibres completely encircle mouth
- In action when pursing lips eg. Whistling
- O: Some fibres from midline maxilla, others from
other muscles in the group
- I: Skin and mucous membrane in lips and into itself
- Modiolus - chiasm of facial muscles
Buccinator
- Muscular component of the cheek
- Trumpeter’s muscle
- Pierced by the parotid duct
- Used when forcefully expelling air from cheeks
- O: Posterior part of the maxilla and mandible opposite molars and pterygomandibular raphe
- Fibres pass forwards between maxilla and mandible (deep to other facial muscles)
- I: Lips, blending with fibres from orbicularis oris

Lower Group of Oral Muscles

Depressor Anguli Oris
- Active during frowning
- Depresses corner of the mouth
- O: Side of mandible, below canine, pre-molar and first molar
- I: Into skin and upper part of orbicularis oris near the corner of the mouth
Depressor Labii Inferioris
- Depresses lower lip and moves it laterally
- O: Front of mandible, deep to depressor anguli oris
- Fibres travel superiorly and medially
- I: Fibres from the same muscle from contralateral side and fibres of orbicularis oris before merging into the
skin of the lip
Mentalis
- Helps position the lip during drinking or when pouting
- O: Mandible inferior to incisor teeth
- Fibres pass downward and medially
- I: Skin of the chin
- Raises the chin, causing lower lip to protrude, wrinkles on skin of chin
- Could cause dislodgement of dentures

Upper Group of Oral Muscles

Risorius
- Helps produce a grin
- Thin superficial muscle
- O: Fascia covering masseter
- Extends medially
- I: Skin at the angle of the mouth
- Pulls corners of the mouth laterally and upward
Zygomaticus Major
- Helps produce a smile
- O: Superficial muscle zygomatic bone
- I: Skin at the angle of the mouth, blends with fibres of orbicularis oris
- Raise the angle of the mouth and move it laterally
Zygomaticus Minor
- O: zygomatic bone anterior to zygomaticus major
- Runs parallel to zygomaticus major
- I: Upper lip medial to angle of the mouth
- Raise the angle of the mouth and move it laterally
Levator Labii Superioris
- O: Infraorbital rim of maxilla
- I: Skin of upper lip and blends with fibres of orbicularis oris
- Elevates upper lip
Levator Labii Superioris Alaeque Nasi
- Lifter of the upper lip and wing of nose
 - O: Frontal process of maxilla
- I: Skin and cartilage of ala and upper lip
- Elevates upper lip, dilates nares and forms nasolabial furrow
- Sneering expression
Levator Anguli Oris
- Deep muscle covered by other two levators and two zygomaticus muscles
- O: Maxilla, just inferior to infraorbital foramen (canine fossa – superior to root of
Mx canine)
- I: Skin at the angle of the mouth, blends with fibres or orbicularis oris
- Raise the angle of the mouth

AURICULAR Group
Anterior Auricular
- Located anterolaterally, pulls ear up and forward
Superior Auricular
- Located superiorly and elevates the ear
Posterior Auricular
- Located posteriorly and retracts and elevates the ear

Neck Muscle
Platysma
- O: Subcutaneous fascia of the upper quarter of the chest
- I: Subcutaneous fascia and muscles of chin and jaw (and mandible)
- Tenses skin of the neck and can move lower lip and corners of the mouth
down

FACIAL NERVE
Cranial Base

V3 exits skull through foramen ovale (in sphenoid bone)

VII exits skull through stylo-mastoid foramen (in temporal bone)

Terminal branches travel through parotid substance and exit through

stylomastoid foramen
Damage to the Facial Nerve
Bells palsy

Damage to facial nerve

Loss of muscle tone

WEEK 2: DR SFERA

OSTEOLOGY OF THE SKULL

THE SKULL
- Provides protection for the brain and sense organs
- Provides attachments for the muscles that hold and move the head
- Made up of irregular bones, joined by sutures
- Cranial bones – neurocranium
- Facial bones – viscerocranium

Dentist Significance
- Base during palpitation of soft tissues
- Markers for identifying soft tissue lesions
- Landmarks in radiography
- Examined for hard tissue lesions
- Landmarks in local anesthesia

Neurocranium consists of:

- Cranial Vault
o Frontal
o Occipital
o Parietal (x2)
o Temporal (x2)
o Sphenoid
- Cranial Base

Vault
- Architectural term for an arched form used to provide a space with a ceiling or roof

Suture
- Immovable articulation of bones
- Filled up with fibrous tissue and Wormian bones
- Most flexible in infants
- Roles:
o Absorbing the force of an impact by moving minimally
o Accommodating the growing brain
o Allowing a degree of flexibility of the skull of a newborn in order to facilitate the passage through birth
canal
Fontanels and Sutures in an Infant Skull

Growth of the Cranial Vault

- Remodeling and growth primarily at the periosteum lined sutures
- Periosteal activity also changes the inner and outer surface of the bones

- As the brain grows, it expands the bones of the vault and stimulates the apposition of new bone on the
suture margins of the flat bones
- It is a response to the forces of pull produced by the connective tissue fibres of the non-fused sutural
articulations
- The bone also gets removed from the inner surface while it gets added to the outer surface – change of
contour

Cranial Base
Anterior Cranial Fossa
- Bones:
o Frontal
o Cribriform plate of ethmoid
o Lesser wing of sphenoid
- Medial part makes the roof of the nasal cavity
- Lateral part makes the roof of orbits
Middle Cranial Fossa
- Bones:
o Body and greater wing of sphenoid
o Petrous part of temporal
- Significant structures:
o Pituitary gland (hypophysis)
o Foramen ovale
o Foramen rotundum
o Superior orbital fissure
o Foramen spinosum
o Optic foramen

Posterior Cranial Fossa

- Bones:
o Occipital
o Temporals
- Significant structures:
o Foramen magnum
o Hypoglossal canal
o Internal acoustic meatus
o Jugular foramen

Foramina of the Cranial Base

Viscerocranium consists of
- Palatine (x2)
- Vomer
- Lacrimal (x2)
- Nasal (x2)
- Inferior Nasal Concha (x2)
- Zygomatic (x2)
- Maxillary (x2)
- Mandible

BONES OF THE SKULL

Cranial
- Occipital
- Frontal
- Parietal (paired)
- Temporal (paired)
- Sphenoid
- Ethmoid

Facial
- Palatine (paired)
- Vomer
- Lacrimal (paired)
- Nasal (paired)
- Inferior Nasal Conchae (paired)
- Zygomatic (paired)
- Maxillary (paired)
- Mandible
SUTURE LINES

Frontal Bone
- Single
- Forms the forehead and roof of orbits
- Articulations – Par, Sph, Lac, Nas, Eth, Zyg, Mx
- Features:
o Frontal sinuses
o Supraorbital ridges
o Supraorbital notch
o Glabella
o Frontal eminence
o Zygomatic process

Parietal Bone
- Paired
- Flat bone
- Articulates – other parietal (sagittal suture)
- Articulations – Fr, Sph, Tem, Occ
- Features:
o Inferior and superior temporal line
Temporal Bone
- Paired
- Houses auditory and vestibular apparatus
- Articulations – Zyg, Par, Occ, Sph, Md
- Portions:
o Squamous Portion
 Part of cranial vault
 Zygomatic process
 Articular (Glenoid) fossa
 Articular eminence
o Tympanic Portion
 External acoustic meatus
 Petrotympanic fissure
o Petrous Portion
 Mastoid process/air cells
 Mastoid notch
 Styloid process
 Stylomastoid foramen (CN VII)
 Carotid canal
 Jugular notch of temporal bone
 Internal acoustic meatus (CN VII and
VIII)

Occipital Bone
- Single
- Posterior cranial fossa/posterior part of the vault
- Articulations – Par, Sph, Tem
- Features:
o Foramen magnum
o Occipital condyles articulate with 1st vertebra (atlas)
o Basilar portion
o Pharyngeal tubercle
o Jugular notch of occipital bone
o Hypoglossal canal (CN XII)
Sphenoid Bone
- Single
- Midline, middle cranial fossa
- Articulations – Fr, Par, Eth, Tem, Zyg, Mx, Pal, Vom, Occ
- Portions:
o Body
 Sella Turcica – pituitary gland
 Sphenoidal air sinuses
o Lesser Wing (ala minor)
 Floor of anterior cranial fossa/roof of orbit
 Optic foramen (CN II)
 Superior orbital fissure (CN III, IV, V1, VI)
o Greater Wing (ala major)
 Floor of middle cranial fossa/lateral wall of orbit/cranial vault
 Inferior orbital fissure (infraorbital nerve and artery, zygomatic nerve)
 Foramen rotundum
 Foramen ovale
 Foramen spinosum
o Pterygoid process
 Inferior surface of the skull
 Attachment of muscles of mastication
 Lateral pterygoid plate
 Medial pterygoid plate – pterygoid hamullus
 Pterygoid fossa
 Pterygo-maxillary fissure
Ethmoid Bone
- Single
- Midline, anterior cranial fossa
- Nasal septum
- Medial wall of orbit
- Articulations – Fr, Sph, Lac, Mx, Vom
- Features:
o Crista galli
o Cribriform plate
o Perpendicular plate
o Lateral masses
o Superior nasal concha
o Middle nasal concha

Vomer

- Single
- Posterior part of nasal septum
- Articulations – Eth, Pal, Mx, Sph, nasal cartilage
- No muscle attachments

Nasal Bone
- Paired
- Bridge of the nose
 - Articulations – Fr, Mx, other Nas, Eth

Lacrimal Bone
- Paired
- Medial wall of orbit
- Articulations – Eth, Fr, Mx, Inf Nas Concha
- Nasolacrimal duct

Inferior Nasal Concha

- Paired
- Lateral wall of nasal cavity
- Articulations – Eth, Lac, Pal, Mx

Zygomatic Bone
- Paired
- Cheek bones (malar)
- Articulations – Fr, Tem, Sph,

Mx
- Surfaces:
o Malar
o Temporal
- Processes:
o Frontal
o Maxillary
o Temporal
o Orbital
- Structures:
o Wall of orbit
o Inferior orbital margin
o Zygomatic arch
 o Temporal/infratemporal fossa

Zygoma
- Bony arch of the cheek formed by connection of the zygomatic and temporal bones

Palatine Bone
- Paired
- L-shaped – vertical and horizontal plane
- Articulations – Mx, Sph, Inf Nas Concha
- Processes:
o Orbital
o Pyramidal
- Structures:
o Posterior part of the hard palate
o Lateral wall of nasal cavity
o Floor of the orbit
- Features:
o Greater palatine foramen
o Lesser palatine foramen
Maxillary Bone
- Paired
- Intermaxillary suture
- Articulations – Fr, Lac, Nas, Inf Nas Concha, Vom, Sph, Eth, Pal, Zyg
- Structures:
o Floor of the orbit
o Floor and lateral wall of the nasal cavity
o Roof of the oral cavity
- Surfaces:
o Anterior/facial
o Superior/orbital
o Medial/nasal
o Posterior/infratemporal
- Body + 4 Processes:
o Frontal
o Zygomatic
o Alveolar
o Palatine

Anterior (Facial) Surface

- Inferior orbital margin
- Infraorbital foramen
- Frontal process
- Nasal notch
- Anterior nasal spine
- Zygomatic process
- Zygomatico-alveolar ridge
- Canine fossa
- Canine eminence
 - Alveolar process

Superior (Orbital) Surface

- Contributes to the floor of the orbit
- Inferior orbital fissure (infraorbital nerve and artery, zygomatic nerve, V1
- Infraorbital groove/canal (infraorbital nerve and artery, anterior superior alveolar nerve)

Nasal Surface
- Lateral wall of the nasal cavity
- Maxillary hiatus – opening of the Mx sinus
- Lacrimal groove (nasolacrimal canal)
- Palatine groove (palatine canal)

Posterior (infratemporal) Surface

- Makes the floor of the infratemporal fossa
- Maxillary tuberosity
- Posterior superior alveolar foramina (posterior superior alveolar
nerve and artery)
Palatine Process
- Extends medially
- Hard palate
- Articulations – Pal, Mx
- Intermaxillary suture
- Transverse palatine suture
- Incisive foramen and canal

Alveolar Process
- Extends inferiorly
- Support ofr Mx teeth
- Buccal and palatal cortical plate
- Interdental septa

Frontal Process
- Extends superiorly
- Articulations – Fr, Nas, Lac
- Anterior boundary of lacrimal groove

Zygomatic Process
- Extends laterally
- Articulation – Zyg

Mandible
- Single bone
- Largest and strongest
- Only moveable bone of the skull
- Articulation – temporal bone (TMJ), teeth of maxillae
- Functions – mastication, swallowing, speech
- Body and 2 rami

Anterior View
- Body
- Alveolar process
- Mandibular symphysis
- Mental protuberance
- Mental tubercle
- Mental foramen
 - Ramus

Lateral View
- Body – external oblique line
- Alveolar process
- Ramus
o Coronoid process
o Condylar process – head and neck
o Coronoid notch
o Mandibular notch
- Angle

Medial View
- Genial tubercles (mental spines)
- Digastric fossa
- Mylohyoid line
- Mylohyoid groove
- Sublingual fossa
- Submandibular fossa
- Retromolar triangle
- Internal oblique ridge
- Mandibular foramen
- Lingula mandibule
- Pterygoid fovea
BONES OF THE NECK

OPG
WEEK 3: DR SFERA

NOSE, PARANASAL SINUSES AND ORBITS

ANATOMY OF THE NOSE
- Prominent anatomic structure located inferior and medial to the eyes
- Roles – respiration and olfaction
- Pyramidal in form
- Opening to the skull is the piriform aperture – bounded by nasal bones and maxilla
- Bones that make the root (fixed part) of the nose:
o Frontal (nasal process)
o Maxilla (frontal process)
o Nasal
- Major cartilages that form the dorsum and apex (mobile part) of the nose:
o Septal
o Lateral nasal
o Alar
- Minor cartilages that complete the nose:
o Lesser alar (3-4 cartilages)
o Vomeronasal
- Fibrous tissue helps connect cartilages together and posteriorly to the maxilla
- Primary lymphatic drainage is into the submandibular lymph nodes

External Nose
- Nares (nostrils)
o Anterior opening
o At the apex
o Separated by septum – connecting apex to philtrum of upper lip
- Vestibule
o Cavity of the nose opposite to alar cartilage
o Lined by vibrissae (many course hairs)
- Atrium
o Cavity posterior to vestibule
- Fibrous tissue connects cartilages together and to the maxilla
- Lining mucosa is of a respiratory type – pseudostratified columnar epithelium with cilia

NASAL CAVITY
- Located superior to oral cavity and inferior and medial to orbits
- Complex chamber located posterior to the vestibule and atrium of the nose
- Inferior portion larger than superior
- Lined by pseudostratified columnar epithelium with cilia
 o Highly vascular and easily congested
o Blood vessels reflexively dilate and glands secrete in response to irritation – leads to sneezing
- Olfactory epithelium located around cribriform plate in the superior part of the cavity

Piriform Aperture
- Anterior opening bounded by the nasal bones and maxilla

Nasal Septum (Medial Wall)

- Frequently deviates to one side
- Made of:
o Septal cartilage
o Perpendicular plate of the ethmoid bone
o Vomer

Lateral Walls
- Composed of large venous plexuses – appearance of erectile tissues
- 3 large elevations – conchae protrude from the lateral wall
- All paranasal sinuses and nasolacrimal duct drain into the lateral walls
- Sphenopalatine foramen in the posterior portion of lateral walls connects the
nasal cavity to pterygopalatine fossa

Nasal Conchae (Projections of the Lateral Wall)

- Connect the nasal cavity to the nasopharynx
- Each encloses a curved structure – meatus
- Structures that drain into:
o Superior meatus
 Sphenoidal sinus
 Posterior ethmoidal sinus
o Middle meatus
  Anterior ethmoidal sinus
 Middle ethmoidal sinus
 Maxillary sinus
 Frontal sinus
o Inferior meatus
 Nasolacrimal duct

Boundaries of the Nasal Cavity

- Superior
o Nasal, frontal bones, cribriform plate of the ethmoid bone, body of sphenoid bone
- Inferior
o Palatine process of maxilla, horizontal plate of palatine
- Anterior
o Apertura piriforme
o Anterior nasal spine
- Posterior
o Choanae leading to nasopharynx
- Medial
o Perpendicular plate of ethmoid bone, vomer, septal cartilage
- Lateral
o Maxilla, ethmoid, palatine bones, medial pterygoid plate of sphenoid bone, inferior nasal concha,
lacrimal bone

Relations
- Superior – frontal sinus, sphenoid sinus, anterior cranial fossa with frontal lobe of the brain
- Inferior – palate, oral cavity
- Medial – other half of nasal cavity
 - Lateral – maxillary sinus, ethmoid sinuses, orbit, pterygopalatine fossa

OLFACTORY SYSTEM AND INNERVATION AND VASCULARISATION OF THE NOSE

Sensory Innervation
- Olfaction – CN I
- General sensation from divisions of the Trigeminal Nerve:
o Ophthalmic Nerve
 Lacrimal
 Frontal
 Nasociliary
 Anterior ethmoid
o External nasal – skin of the ala and apex of nose around nares
o Internal nasal (medial and lateral) – skin on the internal surface of the nasal cavity
 Infratrochlear - skin of the bridge of the nose, eyelids, conjunctiva and all lacrimal structures
o Maxillary Nerve
 Infraorbital
 Nasal – ala of the nose
 Inferior palpebral – skin of the lower eyelid
 Superior labial – skin of the upper lip
 Anterior superior alveolar nerve – inferior meatus, inferior nasal septum, maxillary sinus,
maxillary central incisor, later incisor, canine and gingiva and mucosa of these teeth
 Posterior superior alveolar
 Zygomatic
 Ganglionic
 Nasopalatine
 From pterygopalatine ganglion
 Enters nasal cavity via sphenopalatine foramen
 Supplies nasal septum
 Greater Palatine
 Branches from the pterygopalatine ganglion
 While descending in palatine canal it gives rise to posterior inferior lateral nasal branch
o Supplies posterior part of lateral wall of nasal cavity in the region of middle meatus
 Posterior Superior Nasal
 Through sphenopalatine foramen into nasal cavity
o Posterior superior medial nasal – supplies posterior portion of nasal septum
o Posterior superior lateral nasal – posterosuperior portion of lateral wall of nasal cavity in
the region on superior and middle nasal concha
Arterial Supply
- Branches of:
o Ophthalmic artery (from internal carotid artery)
o Maxillary artery
o Facial artery
- Vessels derived from the external and internal carotid arteries
- Arteries anastomose along the nose
- Nosebleeds commonly due to trauma to the septal branch of
the superior labial artery from the facial artery

Ophthalmic Artery
- From the internal carotid
- Enters orbit through optic foramen
- Branches:
o Dorsal nasal
 Exits orbit along superomedial border
 Supplies area along the bridge of the nose
o External nasal
 Terminal branch of the anterior ethmoid artery
 Supplies the area along the external nose at the junction between the nasal bone and lateral nasal
cartilage
o Anterior Ethmoid
 Enters anterior cranial fossa through anterior ethmoidal foramen
 Gives rise to nasal branches that travel through cribriform plate into nasal cavity
 Lateral and septal branches – lateral walls and septum of the nose
 Gives rise to terminal external nasal artery
o Posterior Ethmoid
 Enters anterior cranial fossa through posterior ethmoidal foramen
 Gives rise to nasal branches that travel through cribriform plate into nasal cavity
 Lateral branch – part of the lateral wall near the superior nasal concha
 Septal branch – posterosuperior portion of nasal septum

Maxillary Artery
- From the external carotid
- Branches:
o Nasal branch of the infraorbital artery
 Supplies lateral aspect of nose
o Sphenopalatine
 Passes through sphenopalatine foramen to nasal cavity
 Gives rise to posterior nasal branches
 Posterior lateral nasal – nasal concha, mucous membranes and lateral wall
 Posterior septal – continues along nasal septum and enters hard palate via incisive canal
o Greater Palatine
 Travels in palatine canal
 Gives rise to lesser palatine artery
 Supplies soft palate and palatine tonsil
 Exits greater palatine foramen and travels anteriorly toward incisive foramen
 Supplies hard palate gingiva, mucosa and palatal glands
 Provides branches that supply area of inferior meatus

Facial Artery
- From the external carotid
- Passes superiorly immediately deep to posterior belly of digastric muscle and stylohyoid muscle
- Passes along submandibular gland – submental artery
- Passes superiorly over the body of the mandible at the masseter – premasseteric artery
- Continues anterosuperiorly across the cheek to the angle of the mouth – superior and inferior labial arteries
o Superior labial – supplies upper lip
 Septal branch supplies anterior nasal septum
- Passes superiorly along the side of the nose giving rise to the lateral nasal artery
o Septal (Nasal) – supplies the septum
o Alar – supplies the ala of the nose
o Lateral nasal – supplies the ala and dorsal surface of the nose
PARANASAL SINUSES
- Invaginations from the nasal cavity
- Drain into spaces on the lateral nasal wall
- Lined by respiratory epithelium – pseudostratified columnar epithelium with cilia
- Morphology highly variable
- Roles:
o Lightening of the skull bones
o Sound resonation
o Providing mucus for the nasal cavity

FRONTAL SINUS
- Paired
- Located within frontal bone
- Flattened triangular shape
- Supplied by ophthalmic arterial branches and the ophthalmic division of trigeminal nerve
- Superior to nasal cavity
- Asymmetrical
- Not present at birth or present as only small outpouching
- Well-developed by 7-8yrs
- Prime expansion in size when 1st deciduous molars erupt and when permanent molars appear at 6yrs
 - Adult frontal sinus has 2 extensions:
o Frontal – extends superiorly into frontal bone in the region of the forehead
o Orbital – extends posteriorly into the frontal bone over the medial part of the orbit
- Ostium (drainage) via middle meatus and frontonasal duct

Relations
- Superior – anterior cranial fossa and contents
- Inferior – orbit, anterior ethmoidal sinuses, nasal cavity
- Anterior – forehead, superciliary arches
- Posterior – anterior cranial fossa and contents
- Medial – other frontal sinus

SPHENOIDAL SINUSES
- Paired, large
- Irregularly shaped
- In the body of the sphenoid bone
- Asymmetrical
- Drain into the superior meatus

Relations
- Superior – hypophyseal fossa, pituitary gland, optic chiasm
- Inferior – nasopharynx, pterygoid canal
- Medial – other sphenoid bone
- Lateral – cavernous sinus, internal carotid artery, cranial nerves III, IV, V1, V2, VI
- Anterior – nasal cavity
ETHMOIDAL SINUSES (AIR CELLS)
- Variable in number – approximately 3-18 on each side
- Located between superior portion of nasal cavity and orbit with very thin surrounding bone
- Located within lateral masses of ethmoid bone
- Divided into:
o Anterior air cells – open into middle meatus
o Middle air cells – open into middle meatus
 May produce swelling on the lateral wall of the middle meatus – ethmoid bulla
o Posterior air cells – open into superior meatus
- Ethmoid cells may invade any of the other 3 sinuses

Relations
- Superior – anterior cranial fossa and contents, frontal bone with sinus
- Medial – nasal cavity
- Lateral – orbit

MAXILLARY SINUSES
- Paired, each within body of Mx
- Pyramidal in shape
- Size varies
- Enlarges with age but present at birth
- Thin-walled and divided into compartments by septae
- Floor in close contact with the roots of posterior Mx teeth
- Drainage into middle meatus
Maxillary Osium – Opening of the Mx Sinus
Maxillary Sinusitis
- Primary – bacteria, viruses, allergy
o Acute or chronic
o Symptoms can mimic endodontic or periodontal infection of Mx posterior teeth
- Secondary
o Infected adjacent teeth
o Oroantral communication

ORBIT
- Pyramid shaped bony recess in the anterior part of the skull
- Lined by periosteum – periorbital fascia

Contents
- Eyeball
- Extrinsic eye muscles
- Optic nerve
- Oculomotor nerve
- Ciliary ganglion
- Trochlear nerve
- Ophthalmic division of Trigeminal
- Abducens nerve
- Ophthalmic artery and branches
- Superior and inferior ophthalmic veins
- Lacrimal apparatus
- Fatty tissue
Walls
- Superior – frontal, lesser wing of sphenoid
- Inferior – maxilla, zygomatic, palatine
- Medial – maxilla, lacrimal, ethmoid, sphenoid
- Lateral – zygomatic, greater wing of sphenoid

Openings
- Optic foramen
o Optic nerve
o Ophthalmic artery
- Superior orbital fissure
o Oculomotor nerve (III)
o Trochlear nerve (IV)
o Abducens nerve (VI)
o Branches of ophthalmic division of V (V1)
 Lacrimal
 Frontal
 Nasociliary
o Superior and inferior ophthalmic veins
- Inferior orbital fissure
o Infraorbital nerve and vessels
o Zygomatic division of V (V2)
- Nasolacrimal canal
o Nasolacrimal duct
Lacrimal Apparatus

MUSCLES OF MASTICATION
MASTICATION
- Process of chewing food in preparation for deglutition (swallowing) and digestion
- Making smaller pieces from larger ones – increasing the area for digestive breakdown
- Helping softening and lubrication of food by saliva
- Major muscles of mastication originate on the skull and insert on the mandible
- All innervated by the mandibular division of the trigeminal nerve
- All are derivatives of the 1st pharyngeal arch
- Four paired major (primary) muscles:
o Temporalis
o Masseter
o Lateral pterygoid
o Medial pterygoid
- Other involved muscles:
o Muscles of the tongue
o Some of the muscles of facial expression – buccinator, orbicularis oris
o Suprahyoid and infrahyoid muscles
- Movement of the mandible in 1 of 3 planes in antagonistic fashion
o Elevation/depression
o Protrusion/retrusion (retraction)
o Side to side excursion (lateral deviation)
TEMPORALIS
- Fan-shaped
- Main postural muscle – maintaining position at rest
- Located on lateral surface of skull
- O: Temporal fossa along inferior temporal line, temporal fascia
- I: Coronoid process – apex, anterior and posterior borders, medial surface and anterior border of the ramus
to the 3rd molar tooth
- Anterior fibres run vertical, posterior fibres run horizontal
- Elevates and retrudes the mandible, aids in lateral excursion
- Innervated by deep temporal nerves of the motor root of V3
o Anterior and posterior deep temporal branches from anterior division of V3
- Blood supply by superficial temporal artery, maxillary artery

MASSETER
- Most powerful muscle of mastication
- Quadrilateral shape
- Two layers (heads) – superficial and deep
- Located on lateral surface of the ramus of the mandible
- Innervated by masseter nerve of anterior division of motor root of V3
- Blood supply by superficial temporal artery, maxillary artery and facial artery

Superficial Head
- Larger
- O: Anterior 2/3 of zygomatic arch and Mx process of zygomatic bone
- I: Angle of Md and inferior and lateral parts of ramus
- Fibres run posteroinferiorly
- Elevation and protrusion

Deep Head
- O: Medial border of posterior 1/3 of zygomatic arch
- I: Coronoid process and superolateral surface of ramus
- Fibres run vertically
- Elevation and retraction (from the protruded position)
SPHENOID BONE – LANDMARKS FOR PTERYGOID MUSCLES
Only the lateral pterygoid plate
serves as an origin

MEDIAL PTERYGOID
- Deepest muscle of mastication
- Quadrilateral shape
- Two heads/bellies – superficial and deep
- Located medial to the ramus of the mandible – infratemporal fossa
- Innervated by medial pterygoid nerve (from V3)
- Blood supply by maxillary artery (pterygoid branches)
- Elevation, protrusion, lateral excursion of the mandible
- Trismus will result from injection of anesthetic during IAN block

Deep Head
- O: Medial surface of lateral pterygoid plate of sphenoid bone
- I: Medial surface of ramus and angle of Md

Superficial Head
- O: Maxillary tuberosity and pyramidal process of palatine bone
- I: Medial surface of ramus and angle of Md

LATERAL PTERYGOID
- Two bellies in transverse direction – upper and lower heads
- Located medial to mandible (infratemporal fossa)
- Innervated by lateral pterygoid branches from anterior division of V3
- Blood supply by maxillary artery (pterygoid artery)
- Depression, protrusion, lateral excursion of the mandible

Upper Head
- O: Infratemporal crest on greater wing of sphenoid bone
 - I: Articular disc and capsule of TMJ

Lower Head
- O: Lateral surface of lateral pterygoid plate
- I: Pterygoid fovea on the neck of condyle

COMBINED MUSCLE
ACTION
- Medial pterygoid and
masseter muscles form a
functional sling around the
angle of the mandible

ACTIONS OF MUSCLES OF

MASTICATION

TEMPOROMANDIBULAR JOINT
STRUCTURAL COMPONENTS
- A joint on each side of the head
- Articulation between the squamous portion of the temporal bone and the condyle of the mandible
- 2 types of synovial joints – hinge and sliding
o Squamous portion of the temporal bone
o Articular disc (dense fibrous connective tissue)
 o Condyle of the mandible
o Capsule ligaments

Squamous Part of the Temporal Bone

- Avascular articular surface covered with dense fibrous connective tissue instead of hyaline cartilage
- Main load bearing areas – lateral aspect of squamous portion, condyle and articular disc
- Dense fibrous connective tissue is thickest in load bearing areas
- Relations:
o Anterior – articular eminence becoming articular tubercle
 Articular eminence – strong bony prominence on the base of the zygomatic arch
 Articular tubercle – lateral part of articular eminence, attachment for capsule and lateral TMJ
ligament
o Intermediate – glenoid fossa
 Glenoid fossa – depression into which condyle is located
 Anterior boundary – articular eminence
 Posterior boundary – tympanic plate
o Posterior – tympanic plate tapering to the postglenoid process
 Tympanic plate – vertical plate anterior to external acoustic meatus
 Postglenoid tubercle – inferior extension of squamous portion of temporal bone, posterior aspect
of glenoid fossa, attachment for capsule and retrodiscal pad

Mandibular Condyles
- Articulate with the articular discs
- Shaped like footballs – mediolateral 20mm, anteroposterior 10mm
- Surface of avascular fibrous connective tissue
 - Main load bearing areas are on the lateral aspects

Articular Disc
- Dense fibrous connective tissue
- Located between the squamous portion of temporal bone and condyle
- Avascular and aneural in the central part
- Vascular and innervated in the peripheral areas where load bearing is minimal
- Main load bearing areas located on the lateral aspect – area for potential perforation
- Merges peripherally attaching to capsule

3 Bands
- Anterior – thick, lies just anterior to condyle with the mouth closed
- Intermediate – thinnest, biconcave, along articular eminence with the mouth closed
- Posterior – thickest, superior to the disc with the mouth closed

Additional Attachments
- Medial and Lateral - medial/lateral collateral ligaments anchor the disc to the condyle
- Anterior – disc attached to the capsule and the superior head of the lateral pterygoid
o No attachment to the condyle allowing the disc to rotate over the condyle in anteroposterior direction
- Posterior – disc is contiguous with the bilaminar zone that blends with the capsule

TEMPOROMANDIBULAR JOINT COMPARTMENTS

- Articular disc divides TMJ into superior and inferior compartments
 o Superior – larger, 1.2mL, between squamous portion of temporal bone and articular disc, translational
movements
o Inferior – smaller, 0.9mL, between articular disc and condyle, rotational movements
- Internal surface lined by synovial membrane – specialized endothelial cells
o Produces synovial fluid – lubricant and nutrients for avascular articular surfaces of the TMJ

Sphenomandibular ligament commonly encountered in IAN block injection – no implications

POSTERIOR ATTACHMENT COMPLEX (BILAMINAR ZONE)

- Bilaminar structure located posterior to the articular disc
- Attaches the disc to the bone and provides nourishment and innervation
- Highly distortable, especially on opening the mouth

Composed of
- Superior retrodiscal lamina (elastic)
o Anchors superior aspect of posterior disc to capsule and bone at postglenoid tubercle and tympanic
plate
o Allows the disk to stretch as it rides over the articulating surfaces during movement of the joint
- Retrodiscal pad
o Main nourishment of the joint – highly vascular and neural
o Loose vascular tissue
o Fills with blood when mandible moves forward
- Inferior retrodiscal lamina
o Made of collagen fibres
o Anchors the inferior aspect of posterior disc to the condyle
o Prevents the disk from slipping off the condyle
TMJ CAPSULE AND LIGAMENTS
- Completely encloses the TMJ
- Fibrous connective tissue
- Toughened along the medial and lateral aspects by ligaments
- Lined by highly vascular synovial membrane
- Highly innervated by sensory receptors

Attachments
- Superior – along the rim of the temporal articular surfaces
- Inferior – along the condylar neck
- Medial – blends along the medial collateral ligament
- Lateral – blends along the lateral collateral ligament
- Anterior – blends with the superior head of lateral pterygoid muscle
- Posterior – along retrodiscal pad

Collateral (Discal) ligament

- Connects the disc to the condyle
- Composed of collagenous connective tissue – not stretchy
- Medial collateral ligament – connects medial aspect of articular disc to medial pole of condyle
- Lateral collateral ligament – connects lateral aspect of articular disc to lateral pole of condyle

Temporomandibular (lateral) ligament

- Thickened lateral aspect of the capsule
- Prevents lateral and posterior displacement of the condyle
- Outer oblique part – largest portion, attached to articular tubercle, travels posteroinferiorly to attach
immediately inferior to condyle, limits opening of mandible
- Inner horizontal part – smaller band, attached to articular tubercle, runs horizontally to attach to lateral part
of condyle and disc, limits posterior movement of articular disc and condyle

Stylomandibular ligament
- Thickening of deep cervical fascia
- From the styloid process to the posterior margin of the angle and ramus of the mandible
- Limits anterior protrusion

Sphenomandibular ligament
- From the spine of the sphenoid bone to the lingula mandibule
- Maintains the same amount of pressure during opening and closing
- Most frequently damaged in IAN block
INNERVATION AND VASCULARISATION OF THE TMJ
Arterial Supply
- External carotid artery - superficial temporal branch
- Maxillary artery - deep auricular and anterior tympanic branches

Venous Drainage
- Retromandibular vein via superficial temporal and maxillary veins

Sensory Innervation
- Anterior division of Trigeminal nerve - masseteric and posterior deep temporal nerves
- Posterior division of Trigeminal nerve – auriculotemporal nerve

MOVEMENT IN THE
TMJ
- Protrusion of the mandible – bringing it forward
- Retraction – bringing it backwards
- Depression – lowering
- Elevation – raising
- Lateral deviation/excursion – shifting to one side

Opening of the Jaws

 - Both depression and protrusion of the Md involved
- Rotation in the lower compartment of the TMJ initiated by the inferior head of the lateral pterygoid muscle
bilaterally
- Translation/gliding of a disc/condyle complex down the articular eminence (in the upper compartment)
- Hyoid bone stabilized by the contraction of the posterior suprahyoid and infrahyoid muscles
- Contraction of the anterior suprahyoid muscle causes the Md to depress

Opening of the Mouth

- Initiation movement rotation in the lower compartment
- Inferior head of lateral pterygoid muscles initiate
- Medial and lateral collateral ligaments tightly attach the disc to the condyle – allowing only rotational
movement
- Rotation continues until the upper and lower teeth are separated – approx. 20mm away from each other
- Once the TMJ is taunt no further rotation can occur
- Further opening uses translation in the upper compartment
- Articular disc and condyle complex slide inferiorly on the articular eminence until its lowest point
- Suprahyoid muscle involved

Closing of the Jaws

- A reverse sequence of gliding and rotational movements
- Retrusion and elevation of the Md
- Performed by contraction of masseter, temporalis and medial pterygoid muscles

Physiological Rest Position

- Teeth are not constantly in occlusion
- A freeway space of 2-4mm exists
- Muscular balance and proprioceptive feedback allow the freeway space
Cuspal Contacts in Centric Occlusion

Lateral Deviation
- Non-identical movement in the left and right TMJ
- During the lateral deviation to the left:
o Right lateral pterygoid muscle contracts
o Right condyle moves forward causing mandible to deviate to the left
- Reverse situation for the lateral deviation to the right

POWER STROKE
- When the teeth crunch food
- Movement from the laterally deviated position back to the midline
- If the food is on the left – the Md deviated by the right lateral pterygoid muscle
- The power stroke involves posterior portion of the right temporalis muscle
- Performs the retraction on the right side
- At the same time, all the closing jaw muscles on the left contract to crunch the food
- The reverse occurs if the food is on the right

DEGLUTITION (SWALLOWING)
- Coordinated action of muscles of the tongue, soft palate, mastication and suprahyoid muscle
- Sends the prepared bolus of food from the oral cavity to the pharynx and then esophagus and stomach
- Teeth are stabilized in the centric occlusion by the bilateral contraction of the elevators of the MD
- Simultaneous contraction of palatoglossus, styloglossus and intrinsic muscles of the tongue
- Tongue firmly pressed onto palate
- Oropharyngeal ishtmus reduced
- Palatopharyngeus muscle, levator veli palatini muscle and uvulae muscle help closing the communication
between nasopharynx and oropharynx
- Suprahyoid muscles (both anterior and posterior groups) lift the hyoid bone and facilitate the passage of the
bolus
- Muscles of the pharynx elevate the pharynx and larynx and help driving the food toward the esophagus
- Epiglottis closes the larynx and the respiratory passage
Infantile (Immature) Swallowing

Tongue Thrust Swallowing

DISEASE PROCESS IN THE TMJ

- Arthritis – most common
o Rheumatoid
 More severe
 Caused by immune system attacking the body
 Can affect any age, common between 20-60yrs
 Symptoms felt throughout entire body
 Affects more women
o Osteoarthritis
 Generally less severe
 Caused by wear and tear on the body
 Generally affects people over 40yrs
 Usually only affects the joints
 Commonly found in both men and women
- Ankylosis
o Obliteration of the TMJ space with abnormal osseous morphologic features
o Due to trauma/inflammation
- Chronic TMJ Disorder
o Chronic joint tenderness
o Swelling
o Muscle spasms
o Limited opening

Mandibular Dislocation (Subluxation of TMJ)

- Condyle moves anteriorly to the articular eminence
- Mouth appears wide open
- Causes – extended dental treatment, trauma, yawn
- Relocation – manual repositioning of the condyle
WEEK 4: DR JENNINGS

GROSS ANATOMY OF THE NECK

THE NECK
- Anteriorly extends from the lower border of the mandible and manubrium
- Posteriorly from the superior nuchal line to the intervertebral disc between C7 and T1 vertebrae

COMPARTMENTS
- Four compartments, each contained within layers of cervical fascia
- Superficial fascia – contains platysma
- Investing layer – completely surrounds neck, attach posteriorly to spinous processes of vertebrae, splits to
enclose trapezius and sternocleidomastoid muscles
- Prevertebral layer – cylindrical layer surrounding vertebral column and prevertebral muscles including
scalene muscles
- Pretracheal layer – collection of fascia’s that surround the trachea, oesophagus and thyroid gland, anteriorly
stretches from hyoid to thoracic inlet
- Carotid sheath – fascial column that surrounds carotid artery, internal jugular and vagus nerve as they pass
through the neck
FASCIAL SPACES

- Important clinically as they provide a conduit for spread of infection especially down into the superior
mediastinum
- Communication between spaces is common
- Dental infection in teeth in the maxilla or mandible can spread to pharyngeal and retropharyngeal spaces
LUDWIG’S ANGINA
- Potential for infection to spread through into the neck
- Due to tight constricting investing layer of fascia – any spread of infection puts pressure on the structures in
the neck and airway
- Involves spread on infection from mandibular teeth to one space initially – eg. Submental or submandibular
- If infection then spreads to the retropharyngeal ‘danger’ space oedema of the larynx may cause complete
respiratory obstruction - incompatible with life
- Acute medical emergency requiring immediate hosptialisation
- Increase in incidence of pierced oral structures (eg. Tongue) has resulted in an increase in infections

BONY STRUCTURE OF THE NECK

- Hyoid bone and 7 cervical vertebrae

Hyoid Bone
- Small u-shaped bone which does not directly articulate with any other skeletal elements
- Highly mobile
- Provides attachments for many muscles
- Superiorly attaches to floor of the mouth
- Inferiorly attaches to larynx
- Posteriorly attaches to pharynx
Cervical Vertebrae
- Small bodies bifid spinous processes and transverse processes that contain foramina (foramen
transversarium)
- C1 and C2 are atypical

REGIONS OF THE NECK

- Neck divided into anterior and posterior triangles for descriptive purposes
- Anterior triangle – anterior border of SCM, inferior border of mandible and midline of neck
- Posterior triangle – posterior border of SCM, anterior border of trapezius and middle 1/3 of clavicle

Sternocleidomastoid
- O: upper part of manubrium (sternum) and superior surfaced of medial 1/3 of clavicle
- I: lateral surface of mastoid process and superior nuchal line
- N: spinal accessory (CN XI)
- Together - draw head forward
- Individually – tilt head towards shoulder on the same side, rotate head to face opposite side

Trapezius
- O: postero-inferior part of the skull, spinous processes of C7-T12
- I: lateral 1/3 of clavicle, acromium and spine of scapula
- N: spinal accessory (CN XI)
 - Rotation of scapula when humerus abducted

Accessory Nerve (XI)

- Exits the cranial cavity via the jugular foramen (along with X and IX)
- Begins to descend medial to the internal jugular vein and internal carotid artery
- Gives off no branches in the anterior triangle
- Innervates the SCM as it passes deep to it
- As it passes through the posterior triangle (deep to investing fascia) it is relatively exposed and susceptible to
injury
- Passes deep to the trapezius to innervate it

Anterior Triangle
- Hyoid essentially subdivides the anterior triangle into a suprahyoid and infrahyoid region
- Muscles in these regions are classified as either suprahyoid or infrahyoid muscles
- All have hyoid in their name – except digastric
- Muscles subdivide the anterior triangle into 4 smaller triangles:
o Submandibular
o Submental
o Muscular
o Carotid

Suprahyoid Muscles
- Consists of 4 muscles
- Can be further divided into anterior and posterior suprahyoid muscles
- All elevate the hyoid and larynx when mandible is stabilized

Anterior Group
 - Anterior belly of digastric, mylohyoid and geniohyoid
- Associated with mastication
- When hyoid stabilized, act to depress mandible and thus open mouth
- Usually lateral pterygoid muscle protrudes mandible and anterior suprahyoid muscles depress mandible

Posterior Group
- Posterior belly of digastric and stylohyoid

Stylohyoid
- From base of styloid process to lateral part of body of hyoid
- N: Facial nerve Vii

Digastric
- Two bellies connected by a tendon attached to body of hyoid bone
- Posterior belly from medial side of mastoid process
- Anterior belly from digastric fossa on inside of mandible
- N: Anterior belly – V3, Posterior belly – VII

Mylohyoid
- Lies superior to anterior belly of digastric
- With its partner from opposite side forms the floor of the mouth
- O: mylohyoid line on the mandible
- Supports and elevates the floor of the mouth
- N: V3

Geniohyoid
- Lies superior to mylohyoid
- O: superior mental spine of mandible
- Passes backwards and downwards
 - I: body of hyoid
- N: C1 via CN XII

Innervation of Suprahyoid Muscles

Infrahyoid Muscles
- N: C1-C3

Sternohyoid
- Posterior and superior sternum
- Inserts into body of hyoid

Sternothyroid
- Posterior surface of sternum (deep and medial to sternohyoid)
- Inserts on thyroid cartilage

Thyrohyoid
- Deep to both sternohyoid and omohyoid
- From thyroid cartilage to body and greater cornu
- Appears as continuation of sternothyroid

Omohyoid
- Lateral to sternohyoid
- Has two bellies
- Posterior belly – from scapula, crosses internal jugular deep to SCM
- Attached by short tendon to anterior belly
- Tendon attached by a sling to medial clavicle
THYROID AND PARATHYROID GLANDS
- Endocrine gland positioned anteriorly in the neck
- Both glands have developmental origins as pharyngeal outgrowths and migrate caudally

Thyroid Gland
- Large, unpaired gland
- Located inferior and lateral to thyroid cartilage
- Consists of two lobes connected by an isthmus (crossing the anterior surfaces of 2 nd and 3rd tracheal
cartilages)
- Lies within the pretracheal fascia together with the pharynx, trachea and oesophagus
- Highly vascular
- Releases thyroid hormones
- Developmentally arises from the floor of the mouth near the base of the tongue
- Foramen caecum indicates the origin of the thyroglossal duct – usually disappears early in development but
may persist as a cyst or fistula
- May be functional remnants:
o Associated with the tongue (lingual thyroid)
o Along the migratory path
o Extending upward from the gland along the path of the thyroglossal duct
Blood Supply
- Superior thyroid artery
o First branch of the external carotid artery
o Splits into anterior and posterior glandular branches
- Inferior thyroid artery
o Branch from the thyrocervical trunk, arising from the first part of the subclavian artery

Venous Drainage
- Superior thyroid vein
o Primarily drains the area supplied by the superior thyroid artery
- Middle and inferior thyroid veins
o Drain the rest
- Superior and middle veins drain into internal jugular vein
- Inferior vein drains into left and right brachiocephalic veins
Recurrent Laryngeal Nerves
- Thyroid gland is closely related to these branches of the Vagus nerve (CN X)
- After branching off from CN X nerves loop under the right subclavian artery and aorta on the left

Parathyroid Glands
- Two pairs derived from 3rd (superior) and 4th (inferior) pharyngeal pouches
- Secrete parathyroid hormone, control of calcium and phosphorous metabolism
FLOOR OF THE MOUTH
ORAL CAVITY

HARD PALATE
- Anterior 2/3 of the hard palate formed by the palatine process of the maxillae
- Posterior 1/3 formed by the palatine bone
Oral Cavity

TONGUE
- Muscular structure
- 2 symmetrical halves separated by a medial fibrous septum

Intrinsic Muscles
- Alter the shape of the tongue
- Longitudinal – superior and inferior
- Transverse and vertical fibres
Extrinsic Muscles
- Move the tongue
- Attach tongue to mandible, hyoid, skull and soft palate

Genioglossus
- Much of the bulk of the tongue
- O: Superior genial tubercle, superior mental spine
- I: Body of hyoid, entire dorsum of the tongue, blend with intrinsic fibres
- Depress centre of tongue and protrude
- Other muscles interdigitate into fibres at side of tongue
- N: XII

Hyoglossus
- O: Greater horn of hyoid
- I: Lateral surface of tongue
- Depresses tongue
- N: XII

Styloglossus
- O: Anterior surface of styloid process
 - I: Lateral surface of tongue
- Retract and draws up sides for swallowing
- N: XII

Palatoglossus
- O: Inferior surface of palatine aponeurosis
- I: Lateral margin of tongue
- Elevates posterior tongue, depresses palate and moves palatoglossal fold towards midline
- N: X via pharyngeal plexus

Innervation
Damage to XII

- Paralysis of genioglossus (tongue falls posteriorly)

- May be as a result of mandible or during GA
- Tongue deviates to side of lesions – due to unopposed action of contralateral genioglossus

LINGUAL ARTERY

Proximity of XII to mandible, may be damaged in #

SOFT PALATE
- Continuation of the hard palate and acts as a valve which can:
o Close the oropharyngeal isthmus
o Separate the nasopharynx from the oropharynx
- 5 muscles contribute to the formation and movement of the soft palate

Tensor Veli Palatini

- Muscle that tenses the palatine curtain
- Two parts:
o Vertical muscular part
o Horizontal fibrous part which forms the palatine aponeurosis
- O: scaphoid fossa on sphenoid, fibrous part of pharyngotympanic tube
- I: palatine aponeurosis
- Tenses the soft palate, opens pharyngotympanic tube
 - N: V3 – branch to medial pterygoid muscle

Palatine Aponeurosis
- Extends form the posterior border of the hard palate and is the major structural element of the soft palate
- Other muscles attach to it

Levator Veli Palatini

- O: Petrous part of the temporal bone
- I: Palatine aponeurosis
- Lifts the soft palate, close isthmus between oropharynx and nasopharynx
- Only muscle that does this
- Say ‘Ahhh” to test – palate deviated away from abnormal side if malfunction
- N: X – via paryngeal branch to pharyngeal plexus

Palatopharyngeus
- O: Superior surface of palatine aponeurosis
- I: Pharyngeal wall
- Depresses soft palate, elevates pharynx (swallowing), moves palatopharyngeal arch toward midline
- N: X – via paryngeal branch to pharyngeal plexus
Palatoglossus
- O: underside of the palatine aponeurosis
- I: lateral side of the tongue
- Depresses palate, moves palatoglossal arch towards midline, elevates back of tongue
- N: X – via paryngeal branch to pharyngeal plexus

Musculus Uvulae
- O: Posterior nasal spine of hard palate
- I: Connective tissue of uvula
- Lifts and retracts uvula
- N: X – via paryngeal branch to pharyngeal plexus
SOFT PALATE
FLOOR OF THE MOUTH
SALIVARY GLANDS
- Secretomotor and parasympathetic submandibular gland (from VII) for sublingual and submandibular glands
- Parotid innervated by fibres from IX
LYMPH – WALDEYER’S RING

PHARYNX
- Musculo-facscial tube that links the oral and nasal cavities in the head to the oesophagus and larynx in the
neck
- Runs from the base of the skull to the oesophagus (C6)
- 3 parts:
o Nasopharynx – posterior apertures of the nasal cavities open into this
o Oropharynx – posterior opening of the oral cavity
o Laryngopharynx – posterior to larynx, including laryngeal inlet

MUSCLES OF THE PHARYNX

- Two groups – dependent on fibre orientation

Constrictors
- 3 pairs of muscles, joined together posteriorly by the pharyngeal raphe
- Innervated by X

Superior Constrictor
- Pterygoid hamulus, pterygomandibular raphe and adjacent bone of mandible
Middle Constrictor
- Greater horn of hyoid, adjacent lesser horn and stylohyoid

Inferior Constrictor
- Cricoid cartilage, oblique line of thyroid cartilage

Longitudinal Muscles
- 3 of these
- Named according to their origins
- All insert into pharyngeal wall

Stylopharyngeus
- From styloid process, descends between superior and middle constrictors, fibres blend into deep pharynx
- Innervated by IX

Salpingopharyngeus
- From cartilage of auditory tube (eustation or pharyngotympanic tube)
- Innervated by X

Palatopharyngeus
- Muscle of the soft palate
- Innervation by X
FASCIA
- Pharyngeal fascia is separated into two layers with the pharyngeal muscles sandwiched between them
- Outside layer is thinner and contributes to the pretracheal layer of cervical fascia
- Fascia reinforces the pharyngeal wall where muscle is deficient
- Above the superior constrictor the pharynx is almost entirely fascia

Pretracheal layer – collection of fascias that surround the trachea, oesophagus and thyroid gland. Anteriorly
stretches from hyoid to thoracic inlet

GAPS
- Gaps in the pharyngeal wall allow structure to pass through them

Innervation
- Except for nasopharynx, both motor and sensory innervation from pharyngeal plexus of nerves on the outer
fascia of the pharynx
- Branches of the vagus and glossopharyngeal nerves
- All motor innervation of muscles in pharynx is from X, except stylopharyngeus – IX
Sensory Innervation
- Nasopharynx – V2, branch originating in the pterygopalatine fossa
- Oropharynx – IX via pharyngeal plexus
- Laryngopharynx – X via pharyngeal plexus

Glossopharyngeal nerve (IX)

- Exits skull through jugular foramen, descends along posterior surface of stylopharyngeus and passes through
the gap between superior and middle constrictors to reach posterior aspect of tongue

LARYNX
- Musculo-ligamentous structure with a cartilaginous framework
- Lies between the trachea below and the pharynx above
- 3 large unpaired cartilages
- 3 smaller paired cartilages
- Suspended from the hyoid, highly mobile in the neck
- Both motor and sensory innervation to the larynx provided by X

Thyroid Cartilage
- Most superior and largest cartilage
 - Laryngeal prominence – Adam’s Apple
- Lateral oblique line – attachment of extrinsic muscles of larynx and inferior constrictor

Cricoid Cartilage
- Most inferior cartilage and completely encircles the airway
- Broader posterior than anterior

Articulation
- Inferior horn of thyroid cartilage articulates cricoid
- Epiglottis is a leaf shaped cartilage
Arytenoid Cartilages
- One of the three paired cartilages

Intrinsic Membranes
- Two functionally important fibro-elastic membranes

Cricothyroid Membrane/Ligament
- Extends between the cricoid cartilage and thyroid cartilage anteriorly
- Superiorly the free border thickens to the vocal ligament (true vocal cord) of the larynx

Quadrangular Membrane
- Extends between the epiglottis and arytenoid cartilages
- Extends anteriorly to the thyroid cartilage
- Thickened free border forms the vestibular ligament (false vocal cord)
Crico-arytenoid Joints
- Quadrangular membrane – synovial joints
o Sliding and rotating action at these joints allows the movements (abduction/adduction) of the vocal
ligaments

LARYNGEAL FUNCTION
- Sphincter for the lower respiratory tract that produces sounds
- Quiet respiration – passageways between vocal folds are open
- Forced inspiration – arytenoid cartilages laterally rotated thus vocal folds abducted and opening widens
- Phonation – vocal folds adducted and the folds vibrate against each other to produce sounds
- Effort closure – when air is retained in the thoracic cavity to stabilize it, eg. When heavy lifting
- Swallowing – opening between the vocal folds closes, larynx moves up and forward causing the epiglottis to
swing down and narrow or close the laryngeal inlet