Review Notes in Head and Neck Anatomy: Article

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MCGILL UNIVERSITY
HEAD AND NECK

ANATOMY
Review notes for dental and medical students
Osama Hussein, MD
2008
©Osama Hussein, 2008
HEAD AND NECK ANATOMY

PREFACE
Good command of anatomy is a basic requirement for studying and practicing clinical
disciplines. A common difficulty that faces many medical and dental students (at least this
was the case with the author) is how to keep their knowledge of anatomical facts in focus
while they move to study clerkship disciplines. Many students build a good repository of
anatomical knowledge in the first two years of medical education but it often does not come
handy when needed in later stages of training. Using these notes, I hope you may find a
quick reference to the information or to where to look for the information. These notes were
written for dental students who have already been familiar with studying anatomy during
their first year but still may find themselves in need for a rapid synopsis to stress the
dentistry-specific information, clinically-oriented applied anatomical concepts and a list of
helpful references for further readings.
About the author:
Osama Hussein is a faculty lecturer at the surgery department of Mansoura University

Medical School in Mansoura, Egypt. At the time of writing, he is pursuing his PhD at McGill
University in Montreal, (QC) Canada under supervision of Dr. Svetlana Komarova, Assistant
Professor at the Faculty of Dentistry in McGill University. Dr. Hussein is an academic cancer
surgeon whose principal interest is in breast cancer. He also practiced head and neck
surgery and co-authored publication in the topic.
All efforts were made to ensure that the contents of these materials are properly cited.
However, the author welcomes all suggestions, corrections and feedback on this material
by e-mail at osama.hussein@mail.mcgill.ca or on his current address at 740 Docteur
Penfield, Rm. 2304, Montreal (QC), H3A 1A4.
Acknowledgment:
The author is grateful to Angella Lambrou and the McGill University Life Sciences Library
staff for their valuable editorial help. The author thanks Dr. S.V. Komarova and Dr. M.
Dagenais at the faculty of dentistry of McGill University for their encouragement to
accomplish this work.
© Osama Hussein, 2008
2


TABLE OF CONTENTS
OBJECTIVES .................................................................................................................................................. 4
SUGGESTED REFERENCES ........................................................................................................................ 6
MANDIBLE AND MAXILLA............................................................................................................................ 7
THE SKULL ....................................................................................................................................................10
TEMPOROMANDIBULAR JOINT (TMJ) ......................................................................................................15
INFRATEMPORAL FOSSA ...........................................................................................................................18
FASCIA OF THE NECK .................................................................................................................................20
LYMPHATIC DRAINAGE OF THE HEAD AND NECK................................................................................22
TRIANGLES OF THE NECK .........................................................................................................................25
THE FACE ......................................................................................................................................................28
LIVING ANATOMY OF THE ORAL CAVITY ................................................................................................35
ANATOMY OF THE PHARYNX ....................................................................................................................37
CRANIAL NERVES ........................................................................................................................................39
TRIGEMINAL NERVE ....................................................................................................................................42
SALIVARY GLANDS .....................................................................................................................................47
3


OBJECTIVES
By the end of your review, you may be able to address the following items:
Bony features of head and neck of interest to the dentist:
I- Describe the morphology, relations and ossification of the maxilla and mandible.
II- Identify general arrangement and major relations of other cranial bones.
Anatomy of the infratemporal region:
I- Describe the contents, arrangements and relations of the major nerves, vessels
and muscles in the infratemporal fossa.
II- Describe the roots and distribution of the otic ganglion.
III- Describe the roots and distribution of the pterygopalatine ganglion.
Anatomy of the oral cavity and pharynx:
I- Identify the surface landmarks in the oral cavity in the living individual.
II- Describe the motor, general sensory and taste sensory nerve supply of the
tongue.
III- Describe the motor, general sensory and taste sensory nerve supply of the oral
cavity.
IV- Describe the motor and sensory nerve supply of the palate and pharynx.
V- Describe the autonomic nerve supply of the minor salivary glands.
VI- Describe the anatomical relations of the palatine tonsils.
VII- Describe the layers of the pharynx.
VIII- Describe the relations of the nasopharynx, oropharynx and laryngopharynx.
Trigeminal nerve:
I- Identify the nuclear origin of both roots of the trigeminal nerve.
II- Identify the distribution of the somatic sensory and motor fibers in the trigeminal
nerve.
III- Describe the course of the trigeminal nerve; exit from the brain stem, dural
relation, the location of the ganglion, exit of the divisions from the cranial
cavity.
IV- Describe the distribution of the ophthalmic, maxillary and mandibular divisions.
V- Identify the branches of the ophthalmic, maxillary and mandibular divisions.
VI- Describe the course and distribution of the nerves.
Arrangements of the fascial spaces and triangles of the neck:
I- Identify the investing, visceral and prevertebral fascial layers.

II- Describe the investing, visceral and prevertebral fascial attachments
III- Describe the derivative fascial envelopes; major salivary gland capsules from the
investing layer, pretracheal fascia from the visceral layer, axillary sheath from
the prevertebral layer and carotid sheath from the junction of the three layers.
4


IV- Identify the communications of different spaces with one another and with
mediastinal and upper limb spaces.
V- Describe the boundaries, contents, relations and communications of the
parapharyngeal space.
VI- Identify the boundaries and communications of the prevertebral, retropharyngeal,
peritonsillar, submandibular and sublingual spaces.
VII- Describe the boundaries and major contents of the triangles of the neck.
Lymphatics and spread of infections:
I- Identify and localize the lymph node groups of the head and neck.
II- Describe the drainage territories of the lymph node groups.
III- Describe the order of drainage from one group to another with appreciation of
variance in communication and collateral and bilateral drainage.
IV- Identify the main lymph node groups draining the gingival, teeth, oral mucosa
and muscles.
Facial nerve, artery, vein and muscles:
I- Identify the nuclear origin of the facial nerve, exit from the brain stem, branches in
the middle ear, branches in the face and nutrient artery.
II- Describe the motor and autonomic distribution of the facial nerve.
III- Describe the course of the facial artery.
IV- Describe the origin, course and communication of the anterior facial, deep facial
and retromandibular veins.
V- Identify the muscles around the mouth, nose and eyes.
VI- Describe the relations, attachments, nerve supply and action of the buccinator
muscle.
Anatomy of local anesthesia:
I- Describe the course of the alveolar nerves.

II- Describe the surface anatomy of the alveolar nerves.
III- Describe the distribution of the alveolar nerves to the corresponding teeth and
gingiva.
Anatomy of the temporomandibular nerve:
I- Identify the type of the joint.

II- Describe the articular surfaces.
III- Describe the ligaments of the joint.
IV- Describe the movements of the joint.
V- Identify the role of the relevant muscles in different movements of the joint.
VI- Describe the relations of the joint.
VII- Describe the factors contributing to the joint stability.
VIII- Describe the nerve supply of the joint.
5


SUGGESTED REFERENCES
Books:
• Textbook of oral and maxillofacial anatomy, histology, and embryology / edited by

S.R. Prabhu.Oxford University Press, 2006.
• Illustrated dental embryology, histology, and anatomy / Mary Bath-Balogh, Margaret

J. Fehrenbach ; illustrated by Pat Thomas. 2nd ed. , Elsevier Saunders, 2006.
Online resources:
• Skandalakis’ Surgical anatomy [electronic resource]: the embryologic and

anatomic basis of modern surgery / E.I.C: John Skandalakis,
http://www.accesssurgery.com/resourceToc.aspx?resourceID=203
• University of Pennsylvania interactive atlas.

http://pennhealth.com/health_info/animationplayer/skull_tool.html
• University of Minnesota self-test.

http://msjensen.cehd.umn.edu/webanatomy/
6


MANDIBLE AND MAXILLA
Alveolar process of each jaw bone is the bony plate that carries the teeth. The root of each
canine makes a smooth elevation on the outer surface of the bone. The depression medial
to it is the incisive fossa. Alveolar process is more dense in the mandible "especially at the
molars" than in the maxilla. Local anesthetics may infiltrate the alveolar process to reach
the maxillary but not the mandibular molars where nerve block is mandatory. In general, the
mandible is the strongest bone of the facial skeleton. In edentulous people the alveolar
process is partially resorbed which makes it more vulnerable invasion of adjacent soft tissue
infection or malignancy.
Key features of the Mandible
External view
• Symphesis menti: ossified junction of two halves of the mandible at the midline.
• Mental protuberance: an elevation on either side of the symphesis.
• Mental foramen: gives exit to the mental nerve. It is situated midway between the
upper and lower margins of the body of the mandible in-between the premolars. it is
directed backwards in adults.
• Coronoid process: the triangular process at anterosuperior end of the ramus.
• Mandibular (Coronoid) notch: on the upper border of the ramus.
• Condyle of the mandible
• Neck of the condyle
• Pterygoid fovea: at the anterior surface of the neck.
• Angle of the mandible.
• Alveolar process.
• External oblique line.
Medial view
• Mandibular foramen: Is found on the medial surface of the ramus midway between the
anterior and posterior borders at the level of the occlusal plane.
• Lingula: Spine of bone hanging in front of the mandibular foramen
• Myelohyoid line: gives attachment to the myelohyoid muscle.
• Myelohyoid groove: extends below the mandibular foramen parallel and posterior to
the myelohyoid line.
• Submandibular fossa: below the myelohyoid line
• Sublingual fossa; above the myelohyoid line.
• Torus mandibularis: Excess bone formation that may be present opposite the canine
area.
• Retromolar triangle: Area of bone behind the last molar which is enclosed by the
diverging tendon of the temporalis muscle.
• Mental spines (Genial tubercles): paramedian attachment for genioglossus above and
geniohyoid below.
• Digastric fossa.
The mandibular ramus is tightly plastered with muscles (masseter laterally and medial
pterygoid medially) to the extent it may not need fixation if fractured (see figure 1). Body
segment fractures will be stable or otherwise depending on the effect of the muscles pull on
7


the fracture segments. This has an impact on surgical procedures involving resection or
fixation of the body of the mandible.
In general the mandible is a strong bone that can resist invasion due to thick trabeculae and
good blood supply from the attached muscles. The weak points of the mandible are:
1. •The edentulous alveolar process.

2. •The retromalar trigone.
3. •The mandibular canal from the mandibular foramen to the mental foramen.
Thrombosis of the inferior alveolar artery may occur leading to osteonecrosis.
The age changes of the morphology of the mandible are relevant to several clinical
situations.
• Mandibular angle tends to be more obtuse at the extremes of age than in adulthood.
• The mandibular canal acquires a relatively higher position with advance of age.
Examine the inner side of the mandible. Notice that the myelohyoid line extends downwards
and forwards. This line corresponds to the attachment of the myelohyoid muscle which
separates the sublingual space above from the submandibular space below. You may
notice that deciduous teeth have shorter roots that will be almost always above the line.
Permanent anterior teeth will have their roots above the line while molar roots will be below
it. Accordingly molar infections may potentially extend to the submandibular space causing
the risky Ludwig’s angina. This complication is rather rare nowadays.
The lingual nerve passes downwards from the infratemporal fossa to enter the mouth just
under the edge of the superior constrictor of the pharynx. The nerve is in a vulnerable
position just under the mucosa of the oral cavity below the last molar where it is liable to
injury.

Figure 1 : Favourable (right) and unfavourable (left) fracture lines of the body of the mandible
8


Key Features of the Maxilla
Anterior view
• Anterior nasal spine
• Alveolar process
• Canine eminence: produced by the root of the canine.
• Incisive fossa: medial to the eminence.
• Canine fossa: lateral to the eminence.
• Infra-orbital foramen: above the canine fossa.
Posterior view
• Maxillary tuberosity: the lower end of the posterior surface behind the last molar.
• Alveolar foramina (2:3)
• Pterygo-palatine groove: it forms a canal with the corresponding groove in the palatine
bone.
Medial view
• Maxillary ostium: communicates the maxillary antrum with the nasal cavity.
• Lacrimal sulcus: lodeges the nasolacrimal duct.
• Conchal crest: for articulation with the inferior concha.
Inferior view
• Incisive foramen: for the sphenpalatine nerve.
• Torus palatinus: median "or symmetrically paramedian" excessive bone formation that
may be found in the hard palate.
Think of the maxilla as a cube (though it is actually more like a pyramid). The posterior
surface is the anterior wall of the pterygo-palatine fossa, the upper is the floor of the orbit,
the medial surface is the lateral of the nasal cavity, the inferior surface is the roof of the
mouth and the anterior surface is in the face. The inside of the cube is the maxillary antrum.
The maxillary nerve in the pterygo-palatine fossa is related to the posterior surface of the
maxilla where it gives the posterior superior alveolar nerve which inters the bone through a
separate foramen in the posterior wall. The maxillary nerve then passes from the fossa to
the orbit through the inferior orbital fissure. The nerves continues forwards on the superior
surface of the maxilla in a groove that turns into a complete bony canal i.e. the nerve sinks
in the bone. In this infraorbital canal the maxillary nerve gives the anterior superior alveolar
nerve that passes laterally in its own canal ‘sinus canal’. Lastly the maxillary nerve exits the
anterior surface of the bone through the infraorbital foramen as the infraorbital nerve. The
maxillary nerve surely deserves its name. The nerve acquires the name of infraorbital at the
inferior orbital fissure in some textbooks. The posterior alveolar nerves may be duplicated.
There may be a middle branch in the posterior part of the infraorbital canal. Alveolar nerves
communicate with one another.
The root of the last molar is separated from the maxillary antrum by a narrow rim of bone.
Affection of either entity by the pathology of the other is not unlikely. Notice the independent
opening of the maxillary antrum on the medial side of the bone. This may make the antrum
more liable to infection due to poor drainage. The size of the hiatus is highly variable.
9


THE SKULL
As a dentist, you will have a thorough knowledge of the structure of the maxilla and
mandible. Other bones are important as much as they facilitate understanding of soft tissue
anatomy.
You may start with reviewing the main landmarks of the skull on the interactive site of
University of Pennsylvania health System Medical Animation Library.
Familiarize yourself with the key features of each bone and the articulated skull views.
These features will be mentioned repetitively in later sections of head and neck soft tissue
anatomy and you can always go back to their definitions while reading.
You can review most of these features at the Pocket atlas of human anatomy : based on the
international nomenclature / Heinz Feneis, Wolfgang Dauber ; [translated by David B.
Meyer] ; 810 illustrations by Gerhard Spitzer. 4th. Edt. Stuttgart : Thieme, 2000.
URL: http://www.thieme.com/SID2191546048372/ebooklibrary/flexibook/pubid-
34408534/index.html
10


MOST RELEVANT KEY FEATURES OF THE SKULL
Key features of the Sphenoid
Body
• Spheno-occipital synchondrosis: cartilaginous joint of the basiocciput with basisphenoid that is
responsible for bone growth that modulates the facial appearance. It closes at early adulthood.
Lesser wing
• Optic canal
Greater wing
• Superior orbital fissure: between the greater wing below and lesser wing above.
• Foramen rotundum: communicates the middle cranial fossa with the pterygopalatine fossa.
• Foramen ovale: communicates the middle cranial fossa with the infratemporal fossa. It transmits the
mandibular (V) and lesser superficial petrosal (IX) nerves, the accessory middle meningeal artery
and an emissary vein.
• Forame spinosum: just behind and lateral to the foramen oval for the middle meningeal artery.
• Foramen venosum (of Visalius): inconstant.medial toforamen ovale for an emissary vein.
• Spine of sphenoid: just behind foramen spinosum for the attachment of the sphenomandibular
ligament.
Pterygoid process
• Medial pterygoid plate

• Lateral pterygoid plate
• Pterygoid notch: in between the diverging lower ends of the two pterygoid plates where the
pyramidal process of the palatine bone is insinuated.
• Pterygoid hamulus: spine at the lower end of the medial pterygoid plate.
• Pterygoid fossa: the surface between the two pterygoid plates.
• Scaphoid fossa: depression at the root of the medial pterygoid plate
• Pterygoid (Vidian) canal: communicates the foramen lacerum with the pterygopalatine fossa.
• Palatovaginal groove: forms a canal with the corresponding groove of the palatine bone.
• Infratemporal crest: the sharp edge between the inferior and lateral aspects of the greater wing of
the sphenoid.
Key features of the Temporal bone
Inferior view
• Mastoid process
• Mastoid notch: medial to the mastoid process. origin to posterior belly of digastric.
• Styloid process; anteromedial to the mastoid process
• Stylomastoid foramen: in between the mastoid and styloid processes. Exit for facial nerve.
• Squamotympanic fissure: suture between the tympanic and squamous parts of the temporal bones.
• Tegmet tympani: a ridge of bone that makes a partition in the medial part of the squamotympanic
fissure
• Pterotympanic and pterosquamous fissures: the medial part of the squamotympanic fissure.
• Mandibular fossa: articulates with the head of the mandible with the articular disc in between.
• Articular eminence: in front of the mandibular fossa.
• Tympanomastoid fissure
• Jugular fossa
• Jugular foramen
• Carotid canal
11


• Tympanic canaliculus: between the carotid and jugular foramena. Inlet for the tympanic branch of
the glossopharyngeal nerve.
Key Features of the Palatine bone
Perpendicular plate
• Pterygo-palatine groove
• Lesser palatine canal
• Spheno-palatine notch
Horizontal plate
• Lesser palatine foramen

• Posterior nasal spine
• Pyramidal process
Norma lateralis of the Skull:
Start with identifying the pterygo-maxillary fissure which is the lateral aperture of the
Pterygo-palatine fossa; A narrow space between the posterior aspect of the maxilla (in
front), pterygoid plate of sphenoid (behind) and the perpendicular plate of palatine bone
(medially). The space contains the maxillary nerve, pterygopalatine ganglion and branches
of the third part of maxillary artery.
Pterygopalatine fossa communicates with:
1-Infratemporal fossa: through the pterygomaxillary fissure transmitting the maxillary

artery.
2-Middle cranial fossa: through the foramen rotundum transmitting the maxillary
nerve and the pterygoid canal transmitting the pterygoid nerve from the foramen
lacerum to the Pterygopalatine fossa.
3- Nasopharynx: through the palatovaginal canal transmitting pharyngeal branches
of the pterygopalatine ganglion.
4- The orbit: through the inferior orbital fissure transmitting the maxillary (to become
the infraorbital) nerve, its zygomatic branch and infraorbital vessels.
5- Roof of the mouth: through the greater and lesser pterygo-palatine canals
transmitting the corresponding nerves and vessels.
6- The nose: through the spheno-palatine canal ttransmitting corresponding vessels
and nerves.
Go back to the individual bones and notice that the pterygo-palatine canal is formed by
coaptation of corresponding grooves of the posterior wall of the maxilla and perpendicular
plate of the palatine bone. Similarly, the spheno-palatine foramen is formed by the
opposition of the corresponding notch at the summit of the perpendicular plate of the
palatine bone with the under surface of the body of sphenoid. The palatovignal canal is
formed by the opposed surfaces of the perpendicular plate of palatine bone and the
sphenoid bone.
12


Normal Basalis Externa of the Skull:
Go to a simplified picture of the skull base (figure 2) and start with identifying the pharyngeal
tubercle at the midline of the spheno-occipital junction (synchondrosis that fuses at 20 to 25
years of age).
From the pharyngeal tubercle, draw an imaginary line that pass laterally and forwards to
cross to the petrous part of temporal bones then changes direction to pass forwards and
medially on the groove between the
petrous and sphenoid bones till it joins
the medial pterygoid plate (the red line in
the schematic illustration). This line
represents the attachment of the
pharyngeal outer wall (Basopharyngeal
fascia). Notice that the apex of the
petrous bone is medial to the line facing
the pharynx. This part of the bone gives
origin to levator palatine muscle which is
thus intrapharyngeal. You can now
appreciate why the foramen lacerum is
closed inferiorly by fibro-cartilage rather
than communicating structures in and
out of the cranial cavity (apart from an
emissary vein from the pharyngeal veins
and the meningeal branch of the
ascending pharyngeal artery). It would
lead to the pharynx not the spaces of the
neck. On the other hand, the tensor
palatine muscle which arises from the
scaphoid fossa at the base of pterygoid
plates of the sphenoid bone (and the
Eustachian tube) is extrapharyngeal. It
thus winds around the pterygoid hamulus
to inter the pharynx between the skull
base and the basopharyngeal fascia
attachment to insert into the “soft” palate.
The fascia over that muscle blends with
the areolar tissue of the region and the
sphenomandibular ligament to form a
partition that travels backwards and
0
laterally at an angle of 45 to reach the
styloid process. (The path of the partition
is represented by the blue line in the
schematic illustration). It crosses the
spine of the sphenoid where the
sphenomandibular ligament attaches.
This partition divides the infra-temporal
fossa into a pre-styloid and post-styloid
13

Figure 2

compartments anterolateral and posteromedial to the septum respectively. Look at the

figure again. The oval foramen is anterolateral to the line remiding you that the lingual nerve
and otic ganglion are in the pre-styloid compartrment (as well as the maxillary and middle
meningeal arteries and the deep lobe of the parotid gland). The jugular and carotid
foramena are posteromedial remiding you that the major neurovascular structures are in the
post-styloid compartment. The chorda tympani emerges from the pteryo-tympano fissure
and traverses from the post-styloid to pre-styloid compartment to join the lingual nerve. You
can easily remember that masses in the pre-styloid compartments may arise from the deep
lobe of the parotid gland or extending from the posterior wall of maxillary sinus. They will
cause symptoms like trigeminal neuralgia due to compression of the mandibular and
maxillary nerves branches. Masses in the post-styloid compartment will compress the
cranial nerves IX to XI (bulbar palsy), jugular vein then internal carotid artery (cerebro-
vascular complications).
Foramen lacerum: it is the defect between the apex of the petrous and the sphenoid
bones. From above it leads to the middle cranial fossa and transmits the internal carotid
artery which emerges from the petrous bone. From below it is closed with fibrocartilage and
may transmit an emissary vein and/or a branch of the ascending pharyngeal artery. In the
middle of the depth of the foramen the greater petrosal nerve emerges from the petrous
bone to join sympathetic branches surrounding the internal carotid artery “named deep
petrosal nerve” to form the nerve of the pterygoid canal. The canal leads the nerve to the
pterygopalatine ganglion in the pterygopalatine fossa. The internal carotid artery and the
greater petrosal nerve emerge from the middle ear inside the petrous bone not traversing
the whole length of the foramen.
14


TEMPOROMANDIBULAR JOINT (TMJ)
Right and left side TMJs work as a single unit because the mandible moves as one piece.
Also, each joint is divided into two compartments by the articular disc.
Articular surfaces:
The mandibular fossa of the temporal bone and articular eminence above, the articular disc
in the middle and the condyle of the mandible below.
Ligaments:
• The capsule is attached to the margins of the articular surfaces and is lax above to
accommodate gliding in the upper compartment and tight below to fit for rotation
movement in the lower compartment.
• The temporomandibular ligament is the thickened lateral part of the capsule and is
directed backwards as well as downwards.
• The sphenomandibular ligament is the remnant of the first branchial arch. It is attached
to the spine of the sphenoid above and the lingual of the mandible below. It is related
laterally to TMJ, inferior alveolar and auriculotemporal nerves, maxillary artery and
deep lobe of the parotid (i.e. lateral compartment of the infratemporal fossa). It is
related medially to the medial pterygoid muscle, chorda tympani and pharyngeal
wall.. It is related anteriorly to the lingual nerve and it is p[ierced by the myelohyoid
nerve. It might interfere with inferior alveolar nerve block.
• Stylomandibular ligament is the thickened investing layer of the deep fascia of the neck
between the capsules of the parotid and submandibular salivary glands.
• Posterosuperior elastic lamina is the posterior extension of the articular disc to the
temporal bone.
• Posteroinferior collagenous lamina is the posterior extension of the articular disc to the
mandible.
Articular disc:
The fibrous disc divides the joint into two compartments. It is saddle above and concave
below. It is tucked at the corners to the condyle of the mandible. It is thickest posteriorly,
thinnest in the middle and medium in thickness anteriorly.
Fat pad:
It is insinuated between the two posterior laminae and contains the vessels and nerves
supplying the joint.
Movements:
• Mild Opening of the mouth: is mainly a hinge-type movement at the lower

compartment. The condyle rotates under the disc. At this stage, the disc is prevented
from gliding by the elastic lamina while the head of the mandible is forced to rotate
due to the sphenomandibular ligament fixing the lingua at a fixed distance from the
skull base i.e. the axis of rotation passes through the fixed point. Gravity, digastric,
geniohyoid and myelohyoid muscles depress the mandible while infrahyoid muscles
fix the hyoid bone in place.
15


• Wide opening of the mouth: Both rotation (mainly inferior) and gliding (of the disc and
condyle on the temporal surface) take place mainly by the inferior head of lateral
pterygoid muscle.
• Mouth elevation: is produced by the masseter, temporalis and medial pterygoid

muscles.
• Protraction: is produced by the lateral pterygoid of both sides acting together. Other
muscles of mastication contract to prevent depression of the mandible by gravity.
• Retraction: is mainly by posterior fibers of temporalis and elastic recoil of the

postersuperior lamina.
• Chewing: repetitive elevation and depression of the mandible accompanied by lateral

deviation of the mandible to the grinding side by the contralateral pterygoids then
back to midline position.
Stability:
Generally any joint in the body is stabilized by the coapting articular surfaces fitting
together, by the surrounding ligaments and by the tone of the antagonist muscles during
movements. Stability factors for TMJ are:
• Fitting of the articular surfaces: The articular eminence of the temporal bone prevents
forward dislocation of the condyle and disc. Also, the articular disc is concavo-
convex from above and totally concave from brelow to fit the mandibular fossa and
eminence and condyle of the mandible respectively. The posterior part of the
articular disc is thicker than the rest of the disc. This part moves forwards on the
non-grinding side during chewing to fill the gap induced by the food in between the
occlusal surfaces. This maintains the stability of the joint on the non-grinding side.
However, apposition of the occlusal surfaces may be as important to TMJ stability as
apposition of the articular surfaces. In the edentulous, the thrust of the mandibular
movements are transmitted directly to the joint and the mandibular angle becomes
wider “obtuse” making forward sliding of the disc and condyle beyond the articular
eminence relatively easier.
• Ligaments: The temporomandibular ligament is directed backwards and inferiorly from

the zygomatic arch to the lateral and posterior aspects of the neck of the condyle.
This prevents backward dislocation of the joint. Superior elastic lamina stabilizes the
articular disc at the initial phase of mandibular depression while the inferior
collagenous band comes into play in the later phase.
• Muscles: The posterior fibers of the temporalis are almost horizontal and prevent the
head of the mandible from dislocating anteriorly. Similarly the upper head of the
lateral pterygoid is also horizontal and prevents the head from dislocating
backwards. Gradual release during agonist function and simultaneous activity during
antagonist function of these muscles steadies the joint during jerky movements.
16


Nerve supply:
Apply Hilton’s law. You will find that the joint should share the nerve supply with the
muscles of mastication. Auriculotemporal nerve is the main nerve supplying the joint.
Masseteric branches also send twigs to the joint. Interestingly pain originating from TMJ or
from spastic conditions of the masseter is often indistinguishable. Glossopharyngeal nerve
sends a tympanic branch that enters the middle ear through the tympanic canaliculus
between the carotid and jugular foramena. Pain from oropharynx may be referred to the
area around the joint and will be correlated with mastication too.
References:
• DVD atlas of human anatomy [videorecording] / Robert D. Acland. Baltimore

: Lippincott Williams & Wilkins, 2004
• Daniel M. Laskin: Temporomandibular disorders: the past, present, and future.

Odontology (2007) 95:10–15
• Textbook of oral and maxillofacial anatomy, histology, and embryology / edited by S.R.
Prabhu.Oxford University Press, 2006.
• Illustrated dental embryology, histology, and anatomy / Mary Bath-Balogh, Margaret J.

Fehrenbach ; illustrated by Pat Thomas. 2nd ed. , Elsevier Saunders, 2006.
• Skandalakis’ Surgical anatomy [electronic resource]: the embryologic and anatomic

basis of modern surgery / E.I.C: John Skandalakis,
17


INFRATEMPORAL FOSSA
The space behind the maxilla on each side of the pharynx is the infratemporal fossa.
Boundaries:
• Medial boundary: from behind forwards; the superior constrictor of the pharynx, tensor
palate muscle, lateral pterygoid plate of sphenoid bone.
• Laterally: The ramus of the mandible.
• Anteriorly: The posterior surface of the maxilla.
• The greater wing of the sphenoid bone medially and the squamous part of the
temporal bone laterally.
• Posteriorly: The styloid process of the temporal bone and the carotid sheath.
Communications:
• At the anterior end of the medial wall “in front of the pterygoid process” the pterygo-
maxillary fissure communicates it with the pterygo-palatine fossa.
• At the upper end of the anterior wall “above the maxilla” the inferior orbital fissure
communicates it with the orbit.
• At the lateral end of the anterior wall the space between the maxilla medially and the
ramus of the mandible laterally communicates with the buccal space above and the
sublingual space below.
• At the lateral end of the roof ‘the space between the infratemporal crest medially and
the zygomatic arch laterally” communicates it with the temporal fossa.
• At the roof the foramen ovale and foramen spinosum communicate it with the middle
cranial fossa.
• The posterior boundary is continuous with the post-styloid compartment of the

parapharyngeal space containing the styloid apparatus and the carotid sheath. The
fascial partition between the two compartments is a radiological landmark rather than
a well-developed septum.
Contents:
The muscles of mastication except the masseter, the mandibular nerve, its
branches, its otic ganglion which actually belongs to the glossopharyngeal nerve and
the chorda tympani, the maxillary artery, the pterygoid plexus of veins, the
sphenomandibular ligament and posterior alveolar vessels and nerves coming from
the pterygo-palatine fossa to pierce the maxilla.
18


General arrangement of the structures in the fossa:
From superficial “lateral” to deep “medial’:
• The ramus of the mandible.
• The lateral pterygoid muscle above with the buccal branch of the mandibular nerve
and maxillary artery emerging between its two heads, the first part of the maxillary
artery directly below the muscle and the lingual and inferior alveolar branches of the
mandibular nerve lower down on the surface of the medial pterygoid muscle.
• Deep to the lateral pterygoid muscle the mandibular nerve gives the two roots of the
auriculotemporal nerve which pass backwards on either side of the middle
meningeal artery then unite together to form the nerve that winds medial then
posterior to the neck of the mandible to reach the superior pole of the parotid gland.
• The deepest structures are the otic ganglion between the mandibular nerve and the
tensor palate muscle, the sphenomandibular ligament behind the ganglion and the
chorda tympani nerve.
The pterygoid plexus of veins are on either side and inside the lateral pterygoid muscle.
The maxillary artery enters the fossa between the neck of the mandible laterally and the
sphenomandibular ligament medially with the auriculotemporal nerve above, then the artery
passes forwards at the lower edge of the lateral pterygoid muscle then dips between its two
heads to enter the pterygo-maxillary fissure. The artery has a variable relation to the lower
head of the muscle; either deep or superficial.
19


FASCIA OF THE NECK
The fascia of the neck consists of three main layers:
• The visceral layer includes the buccopharyngeal, basipharyngeal and pretracheal

fascia.
• The prevertebral fascia forms the axillary sheath.
• The investing fascia includes the capsules of the parotid and submandibular salivary
glands, the sheath of the omohyoid and the suprasternal space.
The carotid sheath is formed from contribution of the three fascial components.
The prevertebral fascia: extends from the base of the skull above to the disc between the
third and fourth thoracic vertebrae below. It encloses the prevertebral muscles, the cervical
and brachial plexuses of nerves and the subclavian artery but not the vein. It extends
laterally around the artery and nerves to form the axillary sheath.
The investing fascia encircles the neck deep to the platysma and encloses the
submandibular and parotid salivary glands. It forms the stylomandibular ligament in
between the two glands. This ligament extends between the angle of the mandible and the
styloid process. The fascia encloses the sternomastoid and omohyoid muscles. The two
layers that enclose the omohyoid remain separated below the level of the muscle down to
the clavicle.
The pretracheal fascia encloses the trachea and the thyroid gland and extends below to the
fibrous pericardium.
The carotid sheath encloses the common and internal carotid arteries, the internal jugular
vein and the vagus nerve. The ansa cervicalis is outside the anterior surface of the sheath
and the sympathetic trunk is outside the posterior surface of the sheath.
Head spaces:
The parapharyngeal space is a quadrilateral pyramidal space on each side of the naso-and
orophrynx.
• Base: The skull base.

• Medial wall: the pharyngeal wall.
• Anterior wall: The maxilla and the vestibule of the mouth.
• Posterior wall: The prevertebral fascia.
• Lateral wall: the ramus of the mandible and the parotid gland.
• The apex: is directed downwards, forwards and laterally. It represents the area of the
carotid triangle of the neck behind and above the tip of the hyoid bone. It is the most
superficial area of the space.
Compartments:
• The pre-styloid space is the infratemporal fossa.

• The post-styloid space is the carotid sheath and the styloid apparatus.
20


The partition between the two spaces is a fascial tissue extending from the tensor palati
muscle to the sphenomandibular ligament to the styloid process. It is more demarcated
radiologically rather than surgically.
The arrangement of the structures in the pre-styloid compartment is discussed with the
infratemporal fossa.
The arrangement of the structures in the post-styloid space:
• Most posteriorly the prevertebral fascia constitutes the posterior limit of the space.
• The sympathetic trunk is in front of the prevertebral fascia.
• The carotid sheath is in front of the sympathetic trunk. The sheath contains the internal
jugular vein, the internal carotid artery and the last four cranial nerves. While the vein
is lateral to the artery in the neck it is more posterior higher up. The vagus is behind
and in between.
• The styloid process is lateral to the sheath.
• The following structures are medial to the internal carotid: The ascending pharyngeal
artery and the superior laryngeal branch of the vagus nerve.
• The following structures intervene between the internal and external carotid: the styloid
process, the stylopharyngeus with its nerve (glossopharyngeal), the styloglossus
muscle, the pharyngeal branch of the vagus and the deep part of the parotid gland.
• The following structures are superficial to both carotid arteries: the posterior belly of
the digastric and stylohuoid muscles and the hypoglossal nerve which winds from
the deepest to most superficial position behind the vessels.
• The spinal accessory nerve is the only one that crosses superficial to the internal
jugular vein.
Communications of the parapharyngeal space:
• Anteromedialy: the paratonsillar space is the classic cause for infection in the
parapharyngeal space.
• Posteromedialy: the retropharyngeal space connecting it with the parapharyngeal
space of the other side.
• Anteriorly: The sublingual space above and the submandibular space below the
myelohyoid muscle. The two spaces communicate behind the posterior edge of the
muscle.
• Inferiorly: The posterior mediastinum.
• Superiorly: the posterior (post-styloid) and middle (pre-styloid) cranial fossae.
21


LYMPHATIC DRAINAGE OF THE HEAD AND NECK
Arrangement of the lymph nodes:
Lymph nodes are classified into superficial and deep groups according to their relation to
the deep fascia. All face nodes are superficial because there is no deep fascia in the face.
Two rings of lymphoid tissue are encircling the craniocervical junction.
The superficial ring from in front backwards is formed of:
• Submental lymph nodes in the midline beneath the symphesis menti.

• Submandibular lymph nodes overlying the submandibular salivary glands.
• preauricular lymph nodes over the parotid gland.
• Retroauricular lymph nodes behind the ear.
• Mastoid lymph nodes at the upper angle of the posterior triangle of the neck.
Other superficial lymph nodes include:
• Buccal node on the buccinator.

• The anterior cervical nodes on the suprasternal notch.
• The superficial cervical nodes on the external jugular vein over the sternomastoid
muscle.
The deep ring is formed of non capsulated lymphoid tissue:
• The palatine tonsil on each side of the fauces enclosed between the palatopharyngeal
arch behind and the palatoglossal arch in front.
• The adenoid at the midline of the posteriosuperior wall of the nasopharynx.
• The lingual tonsil in the midline embedded in the pharyngeal part of the tongue.
The deep cervical lymph nodes:
Receive lymph from all the structures of the neck and head either directly or through the
other lymph nodes and tonsils. These lymph nodes are found in the space between the
investing fascia enclosing the sternomastoid muscle and the carotid sheath fascia. They
could be surgically removed without sacrificing either the sternomastoid muscle or the
contents of the carotid sheath due to the fascial partitions in-between. The nodes are
arbitrarily divided into:
• Upper group above and at the level of the intermediate tendon of the digastric muscle.
• Middle group above and and at the level of the intermediate tendon of the omohyoid
muscle.
• Lower group directly draining into the jugular trunk.
The lymph node situated at the level of the digastic tendon is refered to as the jugulo-
digstric node. It is the main node draining the tonsil.
22


The lymph node at the level of omohyoid tendon is refered to as jugulo-omohyoid node. It
is the main node draining the tongue.
Other deep lymph nodes are:
• Intra-parotid lymph nodes.

• Supraclavicular nodes in the posterior triangle including the scalene node on the
anterior surface of the scalene anterior muscle. This node potentially receives lymph
drainage from the infraclavicular parts of the body being very close to the thoracic or
right lymphatic ducts. When enlarged they may be felt deeply in-between the two
heads of the sternomastoid muscles.
• Accessory nodes on the spinal accessory nerve in the posterior triangle.
• Retropharyngeal lymph nodes.
• Prelaryngeal and pretracheal lymph nodes enclosed inside the pretracheal fascia.
• Paralaryngeal and paratracheal lymph nodes including nodes on the recurrent
laryngeal branch of the vagus.
Lymphatic drainage Pattern:
General trends of lymphatic drainage include:
Lymphatic drainage description is for general guidance only. Lymphatics extensively

communicate with each other and might not respect specific patterns especially in
pathological conditions where the main channels become blocked.
o Midline structures drain bilaterally to lymph nodes in both sides. These structures
include the pharynx, the nose, the tip of the tongue, the pharyngeal part of the
tongue, the incisors and the central part of the oral tongue.
o Posterior structures drain to higher level at the deep cervical lymph nodes while
anterior structures drain to lower level at the deep cervical lymph nodes.
o Posterior structures tend to drain directly into the upper deep cervical lymph
nodes while anterior structures tend to pass through intermediary nodes.
• The tip of the tongue, mandibular incisors and adjacent gingival and buccal mucosa
drain to the submental nodes then to the lower deep cervical lymph nodes.
• The lateral part of the oral tongue, the canine and premolars, the adjacent gingiva,
the vestibule of the mouth, the submandibular salivary gland and the hard palate
drain into the submandibular lymph nodes then to the middle deep cervical lymph
nodes. The pharyngeal part of the tongue, the molar teeth and related gingiva, the
tonsils, the nasopharynx and soft palate drain directly into the upper deep cervical
lymph nodes.
23


• The pharynx drains bilaterally into the deep cervical lymph nodes either directly or
through the retropharyngeal lymph nodes. The nasopharynx also drains into the
posterior triangle lymph nodes.
References:
• Skandalakis’ Surgical anatomy [electronic resource]: the embryologic and

anatomic basis of modern surgery / E.I.C: John Skandalakis,
24


TRIANGLES OF THE NECK

Figure 3
I- Anterior triangle of the neck:
Boundaries:
Superior: the lower border of the mandible.

Lateral: the posterior border of the sternomastoid muscle.
Medially: the midline.
Roof:
The skin, platysma muscle, superficial veins and nerves, deep fascia and the sternomastoid
in the lateral part of the triangle.
Subdivisions:
IA- The submandibular triangle:
Boundaries: the border of the mandible above and the two bellies of the digastric muscles.
It is filled with the submandibular salivary gland.
Floor: the myelohyoid muscle in front and the hyoglossus behind.
Contents: in the anterior part are the superficial part of the submandibular salivary gland,
submandibular lymph nodes, myelohyoid vessels and nerve and the facial artery. The
contents of the posterior part which is related to the hyoglossus are from above downwards
25


the styloglossus, deep part of submandibular salivary gland with its duct, the lingual nerve,
the hypoglossal nerve and the suprahyoid artery.
IB- The submental triangle:
Boundaries: the anterior belly of digastric laterally, the hyoid bone inferiorly and the
midline.
Contents: Submental vessels nerve and lymph nodes.
Floor: The myelohyoid muscle.
IC- The carotid triangle:
Boundaries: the posterior border of sternomastoid laterally, the posterior belly of digastric
muscle above and medially and the superior belly of omohyoid muscle inferiorly and
medially.
Contents: the external carotid artery with its superior thyroid, ascdending pharyngeal,
lingual and facial branches, the carotid sheath containing the internal carotid artery, internal
jugular vein and vagus nerve, the ansa cervicalis and deep cervical lymph nodes overlying
the sheath, the sympathetic trunk deep to the sheath and the superior laryngeal branch of
the vagus near the floor.
Floor: the middle constrictor of the pharynx.
ID1- The muscular triangle:
Boundaries: the posterior border of the sternomastoid laterally, the inferior belly of the
omohyoid muscle superiorly and the midline.
Contents: the respiratory and digestive tracts in the midline, the infrahyoid muscles
covering the thyroid lobe medially, the carotid sheath containing the common carotid artery,
internal jugular vein and vagus nerve laterally.
Floor: is the scalene triangle.
ID2- Scalene triangle:
Boundaries: the medial edge of the scalene anterior muscle laterally, the lower two cervical
vertebrae in the midline and the first rib inferiorly.
Contents: the sympathetic trunk, the recurrent laryngeal branch of the vagus nerve, the
main lymphatic duct of the hemibody to drain into the junction of the internal jugular and
subclavian veins and the inferior thyroid artery.
Floor: the prevertebral fascia enclosing the phrenic nerve and the subclavian artery.
II- The posterior trangle:
Boundaries: the posterior border of the sternomastoid muscle anteriorly, the anterior
border of the trapezius muscle posteriorly and the clavicle inferiorly.
Floor: the prevertebral fascia enclosing the brachial plexus, subclavian artery and
prevertebral muscles "semispinalis capitis, splenius capitis, levator scapulae and scalenus
medius"
26


Subdivisions:
IIA- Suboccipital triangle:
Boundaries: above the lower belly of omohyoid muscle.

Roof: the deep fascia containing the external gujular vein.
Contents: spinal accessory nerve just deep to the roof and occipital lymph nodes at the
apex.
IIB- Supraclavicular triangle:
Boundaries: below the lower belly of omohyoid muscle.

Roof: platysma, supraclavicular nerves and two layers of the deep fascia.
Contents: terminal part of the external jugular vein, supraclavicular lymph nodes,
transverse cervical and suprascapular arteries.
27


THE FACE
Muscles of facial expression:
These are dilator and constrictors (sphincters) of the orifices of the eyelids, nose and
mouth. The muscles of the scalp, ear and neck are rudimentary in humans. Muscles of the
facial expression are generally arranged in two layers. The superficial layer forms part of the
Superficial Muscular Aponeurotic System (SMAS) which is attached posteriorly to the deep
fascia overlying the parotid gland and masseter muscles "parotidomasseteric fascia" and
temporalis muscle "temporal fascia". More anteriorly the SMAS is lax and mobile due to
absence of deep fascia. In general the branches of the facial nerve are superficial to SMAS
and the arteries and branches of the facial artery and trigeminal nerve are most of the time
deep to it. The superficial layer of the facial expression includes the levator labii superioris,
zygomaticus, risorius, depressor anguli oris and platysma. The deep layer includes the
levator anguli oris and buccinator.
Eyelids Constrictors:
1. Orbicularis oculi
• Palpebral part is attached medially to the medial palpebral ligament and

laterally to the palpebral raphe. It closes the palpebral fissure gently as in
blinking and sweeps the tears film from lateral to medial.
• Orbital part is attached to the frontal bone medially and encircles the orbit
laterally. It closes the eye forcibly.
• Lacrimal part surrounds the lacrimal sac to help keeping it open.
Eyelid dilator:
1. Frontal belly of occipitofrontalis.
Nasal dilators:
1. Dilator nasi is the alar part of the nasalis muscle and arises from the maxilla.
2. Levator labii superioris alaeque nasi
3. depressor septi
Nasal constrictors:
1. Compressor naris is the transverse part of the nasalis muscle. It crosses over the
bridge of the nose with an aponeurosis at the midline.
Oral dilators:
1. Levator labii superioris alaeque nasi from the frontal process of the maxilla.
2. Levator labii superioris from the inferior orbital margin.
3. Zygomaticus minor from the zygomatico maxillary suture.
4. Zygomaticus major from the zygoma.
28


5. Risorius from the parotid fascia. These five dilators are arranged in one superficial
plane from medial to lateral. They lie superficial to the trigeminovascular branches
and insert in the upper lip "for the medial two muscles" and the modiolus "for the
lateral three ones".
6. Levator anguli oris is a deeper muscle beneath the trigeminovascular plane that
passes to the modiolous to become superficial and continuous with the depressor
anguli oris.
7. Depressor anguli oris arises from the mandible to the modiolous. It is superficial to
the other muscles. It forms a mirror-image with the elevator anguli oris.
8. Buccinator arises from both jaw bones behind the last molar. It has a vertical linear
origin from bone and fascia. The linear origin starts superiorly from the maxillary
tuberosity, from the pterygomaxillary ligament, from the hamulus of the pterygoid
process, from the pterygomandibular raphe and from the mandible just behind the
posterior end of the oblique line and the base of the retromalar trigone. The
pterygomaxillary ligament bridges over the pyramidal process of the palatine bone
from the maxillary tuberosity to the hamulus of the pterygoid process. The
pterygomandibular raphe stretches between the hamulus and the mandible. The
raphe is of variable thickness so that the superior constrictor muscle fibers may
come in continuity with buccinator or may be separated from it by a good band of
fibrous tissue. The raphe may also be less developed inferiorly than superiorly.
These variations of the raphe determine the degree of the stretch of the buccinator
fibers and the amount of tension they exert on the teeth. The muscle passes
horizontally forwards to the lips. The uppermost and lowermost fibers originating
from bony parts of the jaw pass anteriorly to the corresponding lip tissue without
decussation and blind with the superficial stratum of the orbicularis oris. The middle
fibers originating from the pterygomandibular raphe decussate in the modiolus so
that the higher fibers go to the lower lip and vice versa. These middle fibers blend
with the inner stratum of the orbicularis oris. A fourth lowermost part of the
buccinator has been described to pass from the mandibular origin uninterruptedly
across the midline to form a sling from right to left side. The buccinator is covered
superficially with the skin, buccal branches of the facial nerve, SMAS including
risoruis, accessory parotid gland and transverse facial branch of superficial temporal
artery, the facial artery and vein including a communicating vein with the pterygoid
venous plexus "deep facial vein", buccal pad of fat and the buccopharyngeal fascia.
It is pierced by the parotid duct from outside in and the buccal branches of the
trigeminal from inside out. It is deeply related to buccal minor salivary glands and the
mucosa of the vestibule.
Oral constrictors:
1. Orbicularis oculi has fibers of its own but most of it is formed by fibers converging
from the oral dilators.
2. Incisvus labii superioris.
3. Incisivus labii inferioris. Both incisivus muscles are the deepest muscles of the
orbicularis oris "and the lips" and are attached to the underlying mucosa. They arise
from the corresponding incisive fossa of the corresponding jaw bone. They pass to
the modiolus.
4. Mentalis arises from the mandible medial to the canines and passes inferiorly
through the orbicularis oris to to the skin of the lower lips.
29


Modiolus apparatus:
is a decussation of the muscles of the lip situated one cm lateral to the angle of the mouth
opposite the second maxillary premolar. It is not only a convergence of upper and lower
fibers but also of the deep and superficial fibers.
Importance of the oral muscles:
Anatomy of the peri-oral musculature affects several aspects of dental development and
therapeutics including but not limited to:
• Development of the facial appearance and the degree of ganthism.

• Orthodontic and myofunctional therapies.
• Used surgically as flaps to reconstruct oral congenital or post-resectional defects.
Facial artery:
It arises from the external carotid artery under cover of the anterior belly of the digastic
muscle. Its origin is usually at the same level with the occipital artery that emerges from the
posterior aspect of the external carotid. The origin of the lingual artery is either just below it
or in common with it as the liguofacial trunk. At its origin the facial artery is close to the
middle constrictor of the pharynx in the area above and posterior to the greater cornue of
the hyoid bone where the pharyngeal wall is relatively superficial. The facial artery passes
vertically behind or inside the posterior part of the submandibular salivary gland then
anteriorly between the lateral surface of the gland and the inner surface of the body of the
mandible then the artery enters the face by winding over the lower edge of the mandible at
the anterior border of the masseter muscle i.e. the artery has a rough S-shaped course in
the neck closely applied to the submandibular salivary gland and the mandible.
In the face the artery passes in the face under cover of the skin and SMAS including
platysma, risoruis and zygomaticus muscles. It is deeply related to the mandible, buccinator
and elevator anguli oris. It ends at the medial canthus by anastmosing with branches from
the ophthalmic artery.
Branches:
In the neck:
• Ascending palatine
• Tonsillar. These branches ascend on and then pierce the pharyngeal wall to supply the
tonsil and soft palate.
• Submandibular gland branches.
• Submental to the chin and lower lip.
In the face:
• Inferior labial artery that passes medially in the submucosa of the lower lip.
• Superior labial artery that passes between the deep and superficial layers of the upper
lip dilator muscles to reach the submucosa. The plane of the submucosa is identified
30


during surgery on the lips by recognizing the minor salivary glands as small noules
just beneath the muscular plane. Labial arteries form a continuous circle across the
midline in the substance of the lip.
• Lateral nasal artery.
Communications:
• With the facial of the other side through all its branches in the face.
• With branches from the ophthalmic at the canthus of the eyelids forming a potential
communication of the internal and external carotid arteries.
• With the greater palatine of the maxillary at the tonsil.
• With the infraorbital of the maxillary at the cheek.
• With the sphenopalatine of the maxillary at the nasal septum "Little's area"
• With the ascending pharyngeal of the external carotid at the wall of the pharynx.
Facial vein:
It arises at the medial canthus of the eyelid as the ending of the supraorbital and
supratrochlear veins of the scalp. The corresponding arteries which emerge from the orbit
have venae commitants that communicate with the facial vein at this point. The facial vein
continues downwards closely related to the facial artery. At the middle of the face it diverges
a little posterior and lateral from the artery. At the border of the mandible it does not follow
the facial artery but passes superficial to the posterolateral surface of the submandibular
salivary gland and the digastric muscle. It joins the anterior division of the retromandibular
vein to end in the internal jugular vein.
Although the vein is superficial at the neck, it is still deep to the facial nerve branches and
SMAS "platysma muscle". This fact is useful during removal of the submandibular salivary
gland. The vein is divided, ligated and the upper-sided stump is retracted out of the field.
This guaranties the marginal mandibular branch of the facial nerve is retracted as well and
the lower lip musculature is protected from paralysis.
Communications:
• At its origin with the tributaries of the ophthalmic vein which drains into the cavernous
sinus.
• At the nose with the sphenopalatine and greater palatine of the pterygoid plexus.
• At the mid-face with the pterygoid plexus of veins through the deep facial vein which
passes backwards between the buccinator and masseter muscles to reach the
surface of the ramus of the mandible. It usually passes through the mandibular notch
to the pterygoid plexus. The pterygoid plexus is connected with the cavernous sinus
through emissary veins which pass through the oval foramen, foramen lacerum or
venous foramen if present.
• At the neck with the retromandibular vein i.e. the facial vein communicates with the
superficial temporal vein both at its tributaries in the scalp and its termination at the
retromandibular vein.
31


The dangerous area:
It is the venous territory that potentially communicates with the cavernous sinus. It includes
the central face, nasal mucosa and nasopharynx.
Nerve supply of the face:
Motor nerve supply:
The facial nerve supplies the muscles of facial expression through its terminal branches that
arise inside the parotid gland usually from an upper zygomaticotemporal and lower
cervicofacial divisions. The branches intercommunicate in the anterior part of the gland
forming a pes anserinus "goose foot" pattern. The branches emerge from the anterior
border of the gland and promptly cross the SMAS to become cutaneous i.e. any vertical
skin incision anterior to the parotid gland will potentially cut through one of the branches.
• Temporal: arises from the upper pole of the parotid to supply the frontal belly of
occipito frontalis.
• Zygomatic: arises from the upper part of the anterior border of the gland to supply the
orbicularis oculi.
• Upper buccal: arise from the anterior border of the gland above its duct to supply the
buccinator.
• Lower buccal: arise from the anterior border of the gland below its duct to supply the
upper lip musculature.
• Mandibular: arises from the lowermost area of the anterior border of the gland to
supply the lower lip musculature.
• Cervical: arises from the lower pole of the gland to supply the platysma and gives the
marginal mandibular branch that supplies the depressor anguli oris muscle. The
marginal mandibular reciprocally varies and often replace the mandibular branch.
Sensory nerve supply:
The trigeminal nerve supplies the whole skin of the face except the area overlying the angle
of the mandible which is supplied by the greater auricular nerve from the cervical plexus
(C2). The three divisions of the trigeminal nerve supply the skin of the face;
Ophthalmic division:
• Supratrochlear: to the paramedian area of the forehead.

• Supraorbital: to the forehead.
• lacrimal: to the area above and lateral the lateral canthus.
• Infratrochlear: from the nasociliary to the area of the medial canthus.
• The external nasal: from the anterior ethmoidal of the nasociliary to the nose.
Maxillary division:
• Infraorbital: to the cheek.

• Zygomatic: from the pterygopalatine fossa divides into zygomaticotemporal and
zygomaticofacial which pierce the zygoma at two points to the overlying skin.
32


Mandibular division:
• Auriculotemporal: emerges from the upper pole of the parotid to supply the temple.
• Buccal: multiple branches that pierce the buccinator to the skin below the level of the
angle of the mouth.
• Mental: from the inferior alveolar nerve emerges from the mental foramen to supply the
chin.
Vasomotor nerve supply:
The postganglionic sympathetic fibers mainly from the middle cervical ganglion reach the
skin through the adventitia of the arterial system.
Nerve injuries affecting the face:
Facial nerve injury:
Upper motor neuron lesion "supranuclear" usually due to cerebrovascular accident will
spare the eyelids and forehead because the upper part of the nucleus is supplied from both
hemispheres. The subconscious emotional movements will be spared because they are not
controlled by the motor area of the frontal cortex.
Lower motor neuron lesion "affecting the nucleus or the nerve" will cause:
• Paralysis of the frontalis leading loss of corrugation of the forehead.
• Paralysis of the orbicularis oculi leading to lagophthalmos "failure to close the eyelids"
that will culminate into dry eye, corneal ulceration and blindness if neglected.
• Paralysis of the buccinator leading to accumulation of the food bolus in the vestibule of
the mouth during chewing. The patient will not be able to blow his mouth.
• Paralysi of the orbicularis oris leading to deviation of the angle of the mouth with
smiling or talking. The patient can not whistle or show her teeth.
Lesions in the petrous bone will affect the nervus intermedius as well leading, in addition to
the above, to loss of taste sensation from the anterior two-thirds of the tongue.
Trigeminal neuralgia will lead to chronic pain deep in the middle face that might be
triggered by irritation of the territory of the nerve e.g. tooth or skin.
Frey's syndrome: is due to nerve injury during parotidectomy surgery. The regenerated
sympathetic and parasympathetic fibers communicate together leading to sympathetic
effect induced by parasympathetic impulse i.e. mastication normally stimulates salivary
secretion. With this condition mastication induces sweating. Treatment is by cutting the
auriculotemporal nerve that carries the parasympathetic fibers coming from the chorda
tympani.
33


References:
• Mitz V, Peyronie M: The superficial musculo-aponeurotic system (SMAS) in the parotid

and cheek area.Plast Reconstr Surg. 1976; 58(1):80-8.
• Pensler JM et al: The superficial musculoaponeurotic system in the upper lip: an

anatomic study in cadavers.Plast Reconstr Surg. 1985; 75(4):488-94.
• Gosain AK et al: Surgical anatomy of the SMAS: a reinvestigation.Plast Reconstr Surg.

1993; 92(7):1254-63.
• Ghassemi A et al: Anatomy of the SMAS revisited. Aesthetic Plast Surg. 2003 Jul-;
27(4):258-64.
34


LIVING ANATOMY OF THE ORAL CAVITY

Lips:
• From outside the nasolabial groove is running from the lateral end of the ala nasi
above to the angle of the mouth below. It is an important landmark for surgical
incisions.
• The vermilion surface is the transition from the skin of the outer surface of the lip to the
mucous membrane of the oral aspect of the lip. It consists of modified skin and is
exposed at the resting position with the mouth closed.
Vestibule of the mouth:
Visible landmarks:
• Frenula: mucosal folds on the midline “upper and lower” and laterally.
• Parotid duct opening: in the inner surface of the cheek with a small papilla located
opposite the second maxillary molar tooth.
• Pterygomandibular raphe: A clear vertical ridge behind the last molars with the mouth
widely open.
Palpable landmarks:
• The pterygomandibular raphe.
• The maxillary tuberosity behind the last maxillary molar.
• The coronoid process of the mandible lateral to the maxillary tuberosity. It moves
forwards with opening the mouth.
• The retromalar trigone of the mandible behind the last mandibular molar.
• The lingual nerve below the last mandibular molar.
• The deep tendon of the temporalis muscle extends from the coronoid process down to
the medial edge of the retromalar trigone.
Gingiva:
The gingival mucosa is nonmobile, opaque, pink and stippled in contrast to the alveolar
mucosa which is mobile, shiny, red and not stippled. The free gingiva dips from the gingival
crest to line the gingival sulcus. The interdental papilla is the triangular gingival inbetween
two adjacent teeth. The interdental col is the concave epithelium between the lingual and
labial interdental papillae.
Palate:
• Incisive fossa in the cmidline anteriorly.

• The palatine raphe extending backwards from the incisive fossa.
• The palatine rugae on either side of the raphe.
• The hamular notch lateral to the upper end of the pterygomandibular raphe.
• The hamulus of the pterygoid process of the sphenoid bone behind the notch.
• Torus palatinus may be present in a median or symmetrically paramedian location.
Fauces:
• Palatoglossal fold is an arched fold from the soft palate to the base of the tongue.
• Palatopharyngeal fold is another fold posterior and parallel to it.
35


• The palatine tonsil in between the two folds.
The tongue:
Dorsal surface:
• Sulcus terminalis divides the tongue into posterior third and anterior two-thirds.
• Foramen caecum in the midline of the sulcus.
• Circumvalate papillae just in front of the sulcus terminalis..
• Fungiform and filliform papillae on the dorsum of the anterior two-thirds.
• Foliate papillae on either side of the posterior third.
• Median glosso-epiglottic fold extends backwards from the tongue to the epiglottis.
• Vallecula is a depression on either side of the median glossoepiglottic fold.
• Lateral epiglottic fold lateral to the vallecula.
Undersurface:
• The frenulum in the midline.

• The deep lingual veins on either side of the frenulum.
• The fimbriated fold more laterally.
The floor of the mouth:
• Sublingual fold on either side of the midline frenulum.

• Sublingual papilla at the anterior end of the fold for opening of the submandibular
gland duct.
36


ANATOMY OF THE PHARYNX
The pharyngeal wall is formed of four concentric funnels overlapping one another with
lowermost outside and uppermost inside. From above downwards the four funnels are the
pharyngobasilar fascia which is a condensation of the submucosa that attaches to the base
of the skull, the superior middle and inferior constrictors muscles.
• Superior constrictor is attached from above downwards to the medial pterygoid plate,
hamulus of the pterygoid process, pterygomandibular raphe and the mandible just
below and posterior to the socket of the last molar.
• Middle constrictor is attached from above downwards to stylohyoid ligament and both
horns of the hyoid bones.
• Inferior constrictor is divided into two parts:
1. The upper part is oblique and called thyropharyngeus. It is attached to the

oblique line of the thyroid cartilage above and the fibrous arch over the
cricothyroid muscle below.
2. The lower part is horizontal and called cricopharyngeus. It is attached to the

cricoid cartilage.
All three constrictors muscles are attached posteriorly to a median raphe that attaches
above to the pharyngeal tubercle of the occipital bone. It fades inferiorly at the level of the
vocal cords. There is no raphe at the level of the cricopharyngeus which allows it to function
as a sphincter.
Gaps in between the constrictors are filled with fascia.
• The gap above the superior constrictor is closed with the pharyngobasilar fascia and
transmits the auditory tube, the tensor palate tendon and the ascending pharyngeal
artery.
• The gap between the superior and middle constrictors is filled with the
buccopharyngeal fascia and transmits the stylopharyngeus and styloglossus
muscles and the glossopharyngeal and lingual nerves.
• The gap between the middle and inferior constrictors is filled with the thyrohyoid
membrane and transmits the internal laryngeal nerve and the superior laryngeal
artery.
• The gap in between the thyropharyngeus and cricopharyngeus (Killian’s dehiscence) is

normally closed and may cause a pathological protrusion of the mucosa.
• The gap below the cricopharyngeus is closed with a condensation of the pretracheal
fascia (Berry’s ligament) and transmits the recurrent laryngeal nerve and an
accompanying artery.
37


Stylopharyngeus originates from the deep aspect of the styloid process at its base and is
inserted into the posterior edge of the thyroid cartilage. It is the only muscle supplied by the
glossopharyngeal nerve which accompanies the muscle winding around its posterior and
lateral aspects. Both the muscle and the nerve intervene between the internal and external
carotid arteries then between the superior and middle constrictors of the pharynx.
Salpingopharyngeus and palatopharyngeus are vertical muscles inside the superior
constrictor.
Nerve supply:
Motor:
The muscles are derived from the branchial apparatus and receive motor supply from the
nuclus ambigiuus.
• The stylopharyngeus is supplied by the glossopharyngeal nerve
• All other muscles are supplied by the vagus nerve although these vagal fibers may
travel with the cranial accessory nerve to rejoin the vagus again. The vagus gives
these pharyngeal fibers to the pharyngeal branch which passes deep to the carotid
sheath to join the pharyngeal plexus on the surface of the middle constrictor muscle.
General sensation:
• The nasopharynx is supplied by the trigeminal nerve through the pharyngeal branch of
the maxillary division through the pterygopalatine ganglion.
• The oropharynx is supplied by the glossopharyngeal nerve.
• The laryngopharynx is supplied by the vagus nerve.
Vasomotor:
From the sympathetic postganglionic fibers around the arteries.
Arterial supply:
Ascending pharyngeal (from external carotid), ascending palatine and tonsillar (from facial),
greater palatine, pharyngeal and lingual (from maxillary) and superior laryngeal (from the
superior thyroid).
Venous drainage:
The venous plexus around the middle constrictor muscle drains into the internal jugular vein
and connects with an emissary vein through the foramen lacerum or indirectly through the
pterygoid plexus.
Lymphatic drainage:
Is bilateral to the retropharyngeal lymph nodes then to the deep cervical lymph nodes. The
nasopharynx also drains into the supraclavicular nodes in the posterior triangle.
38


CRANIAL NERVES
Cranial nerves nuclei:
The first and second cranial nerves are CNS tracts not peripheral nerves.
The third to twelveth nerves originate from the brain stem nuclei in a comparable
arrangement to that of the spinal cord i.e. the somatic motor anterior, autonomic lateral and
sensory posterior. Skeletal muscles derived from the branchial apparatus have a distinctive
nucleus different from that of the somatic muscles. The special sensations (taste, hearing
and equilibrium) have their own nuclei.
Somatic motor nuclei:
• The motor nuclei of the third, fourth and sixth nerves to the extraocular muscles.
• The hypoglossal nucleus to the tongue muscles.
• The anterior horn cells of the cervical spine to the sternomastoid and trapezius.
Branchial motor nuclei:
• Motor nucleus of the trigeminal nerve to the muscles of mastication.

• Facial nerve motor nucleus to facial expression muscles.
• The nucleus ambigiuus to the palatal, pharyngeal and laryngeal muscles.
Parasympathetic:
• Edinger-Westiphal nucleus to the constrictor pupillae and ciliary muscles.

• The lacrimatory nucleus.
• The superior salivary nucleus to the submandibular, sublingual and minor salivary
glands.
• The inferior salivary nucleus to the parotid.
Special sensation:
• Vestibular nucleus for equilibrium.

• The choclear nucleus for hearing.
• The nucleus and tractus solitarius for taste, chemsensory apparatus of the carotid and
aortic bodies.
General sensation:
• Proprioceptive first order neurons are in the mesenchephalic nucleus of the trigeminal
nerve.
• Tactile discrimination and deep touch first order neurone is in the trigeminal nucleus
and synapse in the main trigeminal nucleus in the pons.
• Pain, temperature and crude touch first order neurons are in the trigeminal inferior
glossopharyngeal and both vagal ganglia and synapse in the spinal nucleus of the
trigeminal nerve in the medulla oblongata and upper cervical segment.
39


Cranial nerves distribution:
I- Olfactory nerves: from the olfactory mucosa.
II- Optic nerve: from the retina.
III- Oculomotor nerve:
A- Somatic motor to all extra-ocular muscles except the superior oblique and lateral rectus.
B- Parasympathetic to the constrictor pupillae and ciliary muscles.
IV- Trochlear nerve:
Somatic motor to the superior oblique.
V- Trigeminal nerve:
A- General sensory:
From the face except the area overlying the angle of the mandible, from the anterior two-
thirds of the scalp, from the dura mater of the anterior and middle cranial fossae, from the
nasopharynx, from the palate and oral mucosa, gingivae, teeth paranasal sinuses and
anterior two-thirds of the tongue and proprioceptive sensations from the muscles of
mastication, extra-ocular muscles, tongue muscles and the muscles of facial expression.
B- Motor to the muscles of masticastion, myelohyoid, anterior belly of digastric, tensor palati
and tensor tympani.
VI- Abduscence nerve:
Somatic motor to the lateral rectus.
VII- Facial nerve:
A- Branchial motor: to the muscles of facial expression, stapedius, posterior belly of

digastric and stylohyoid.
B- parasympathetic to the lacrimal, submandibular, sublingual and minor palatal and
paranasal glands.
C- Taste sensation from the anterior two-thirds of the tongue and soft palate.
VIII- Vestibulochoclear nerve:
A-Hearing.
B-static and dynamic equilibrium.
40


IX- Glossopharyngeal nerve:
A- Branchial motor to the stylopharyngeus muscle.

B- Parasympathetic to the parotid and lingual salivary glands.
C- Special sensory: taste from the posterior third of the tongue and carotid body.
D- General sensation: from the middle ear, posterior third of the tongue and oropharynx
including most of the tonsil.
X- Vagus nerve:
A- Branchial motor: to all muscles of the pharynx except stylopharyngeus, to all muscles of
the
palate except the tensor palati, to all muscles of the larynx and to striated muscles in the
upper esophagus.
B- Parasympathetic motor: to the muscles and glands of the gastrointestinal tract from the
lower esophagus to the transverse colon.
C- Special sensory; taste from the epiglottis and the aortic body.
D- Visceral General sensory: from the corresponding area of the gastrointestinal tract.
E- Somatic general sensory: from the laryngopharynx, larynx and the posterior wall of the
external ear.
XI- Accessory nerve:
A- Cranial part: Are actually borrowed branchial motor fibers from the vagus.
B- Spinal part: somatic motor from the anterior horn cells of the upper cervical segments to
the trapezius and sternomastoid.
XII- Hypoglossal nerve:
A- Somatic motor to the tongue muscles except the palatoglossus.

B- The nerve borrows fibers from First cervical segment to the thyrohyoid, geniohyoid and
ansa cervicalis to the infrahyoid muscles.
41


TRIGEMINAL NERVE
Nuclear connections:
• Motor nucleus: in the pons which includes the supratrigeminal nucleus. The
supratrigeminal nucleus receives sensory input from the mesenchephalic nucleus
and regulates the motor activities of muscles involved in mastication possibly
including those supplied by the facial and cervical nerves.
• Mesenchephalic nucleus: in the mid-brain receives proprioceptive sensation from

muscles of mastication, facial muscles, tongue muscles and extra-ocular muscles.
• Main sensory nucleus: in the pons receives deep tactile sensation from all the
trigeminal distribution. The face is represented as onion peel i.e. in concentric circle
with the most central part of the face above and the peripheral parts below.
• Spinal nucleus: in the medulla oblongata receives pain and temperature from the
trigeminal, glossopharyngeal and vagus nerves.
Intracranial part:
The nerve emerges from the middle of the pons as a small motor and large sensory root.
The sensory root enlarges into a ganglion that is lodged in the dural cave on the petrous
bone. The ganglion receives its blood supply from the accessory meningeal artery of the
maxillary. It reaches the ganglion through the foramen ovale. The posterior half of the
ganglion has a meningeal sleeve and is bathed in CSF.
The sensory part divides into ophthalmic and maxillary which pass in the lateral wall of the
cavernous sinus and mandibular which joins the motor root.
Exit from the cranial cavity:
• Ophthalmic through the superior orbital fissure.

• Maxillary through foramen rotundum.
• Mandibular through foramen ovale.
Ophthalmic Division:
Divides at the anterior end of the lateral wall of the cavernous sinus into the lacrimal, frontal
and nasociliary nerves. The three branches inter the orbit through the superior fissure. The
nasociliary is inside the tendinous ring of the recti muscles and is in between the two
divisions of the oculomotor. The frontal and lacrimal are outside (lateral) to the tendinous
ring.
a. Frontal nerve: passes just below the roof of the orbit to divide into the supraorbital
laterally and supratrochlear medially. They emerge from the orbit to supply the upper
eyelid and the forehead and in case of the supraorbital the frontal sinus and the
anterior scalp.
42


b. Lacrimal nerve: It supplies the sensory nerves to the lacrimal gland and conveys the
parasympathetic nerves from the zygomaticotemporal nerve. it supplies the lateral
canthus area.
a. Nasociliary nerve:
Behind the globe, it crosses above the optic nerve from lateral to medial
accompanied with the ophthalmic artery to reaches the medial wall of the orbit . It
traverses the ethmoidal foramen to reach the anterior cranial fossa as the anterior
ethmoidal nerve. It enters the slit along the cresta galli to reach the roof of the nasal
cavity. It emerges between the nasal bone and cartilage to reach skin of the nose as
the external nasal.
Branches:
• behind the globe:

o Ganglionic branches which pass without relay to the ciliary ganglion to supply
the whole eyeball.
o long ciliary nerves to the eyeball.
• At the medial wall of the orbit:
o The posterior ethmoidal to the sphenoid air sinus.

o anterior ethmoidal branches to the air cells.
o Infratrochlear to the medial canthus of the eyelids.
• At the anterior cranial fossa it gives supply to the dura.
• At the nasal cavity, it supplies the upper parts of the septum and lateral wall.
• At the face, it supplies the skin of the nose as the external nasal nerve.
Maxillary Division:
Enters the pterygo-palatine fossa through the foramen rotundum where it gives most
of its branches their through the ganglion with the same name. It passes through the
pterygo-maxillary fissure to reach the infratemporal fossa then it passes in the infra-
orbital fissure to reach the floor of the orbit. It enters the infra-orbital canal to run in
the roof of the maxillary sinus and then emerges to the cheek from the infra-orbital
foramen.
Branches:
• In the middle cranial fossa: meningeal branch.
• In the pterygo-palatine fossa (direct or through the ganglion):
43


• Nasopalatine: Enters the sphenpalatine canal to supply the posteroinferior part

of the nasal septum then enters the incisive foramen to reach the oral surface
of the hard palate to supply its anterior part.
• Posterior superior nasal nerves: Enter the sphenopalatine foramen and supply
the posterior nasal mucosa.
• Greater palatine nerve: Enters the greater palatine canal to reach the oral
surface of the hard palate through the greater palatine foramen to supply its
posterior part.
• Lesser palatine nerves: Enters the greater palatine canal to reach the soft
palate through the lesser palatine foramen.
• Pharyngeal branche; Passes through the palatovaginal canal to supply the
nasopharynx.
• Zygomatic Branch: Passes through the infra-orbital fissure to reach the orbit. It
divides into the zygomatico facial and zygomatico temporal which pierce the
zygomatic bone to reach the face and temporal skin respectively.
• Posterior superior alveolar nerve: Divides into two to three branches which
emerge from the pterygo-maxillary fissure and pierce the posterior aspect of
the maxilla. They supply the maxillary sinus, maxillary molars and adjacent
gingiva.
• Branches in the infra-orbital canal:
• Middle superior alveolar nerve: to the maxillary premolar.
• Anterior superior alveolar nerve: to the maxillary canine and incisors.
• Branches in the face:
• Inferior palpebral to lower eyelid
• nasal
• Upper labial
Mandibular Division:
It has a short course from the middle cranial fossa to the foramen ovale to the
infratemporal fossa where it divides into anterior and posterior divisions.
Branches:
From the trunk:
• Nervus spinosus: passes to the middle cranial fossa through the foramen spinosum.
• Nerve to medial pterygoid : supplies the medial pterygoid, tensor palati and tensor
tympani muscles.
44


From the Anterior division:
• Nerves to the temporalis (deep temporal) pass above the lateral pterygoid.
• Nerve to masseter passes above the lateral pterygoid muscle then above the
mandibular notch. It supplies the TMJ.
• Nerve to lateral pterygoid.
• Buccal nerve passes in between the two heads of the lateral pterygoid to supply the
skin of the cheek, mucosa of the vestibule and carries fibers to the minor salivary
glands.
From the posterior division:
• Auriculotemporal: its two roots encircle the middle meningeal artey. It supplies the
parotid gland, the anterior surface of the upper half of the ear pinna, The TMJ and
the skin of the temple.
• Inferior alveolar nerve: passes below the lateral pterygoid muscle to lie medial to the
ramus of the mandible and lateral to the medial pterygoid muscle and the
sphenomandibular ligament. It gives the myelohyoid nerve that pierces that ligament
and supplies the myelohyoid and anterior belly of digastric muscles. The inferior
alveolar nerve then enters the mandibular foramen to supply the molar and
premolars and divides into the mental nerve which exits from the mental foramen
and supplies the lower lip and the incisive nerve that supply the canine and two
incisives.
• Lingual nerve (joined by the chorda tympani): Is at first anterior and parallel to the
inferior alveolar then it passes under the lower edge of the superior constrictor of the
pharynx to enter the oral cavity. It is then directly applied to the medial surface of the
mandible below the last molar tooth. Above the myelohyoid muscle, the nerve is
lateral to the hyoglossus muscle, winds around the submandibular duct to reach the
anterior two-thirds of the tongue, mucosa of the floor of the mouth and lingual
gingiva.
Parasympathetic ganglia:
They receive post-ganglionic sympathetic fibers from the plexus around the adjacent
arteries and somatic sensory fibers from the trigeminal that have no functional relation with
the ganglia .
• Ciliary ganglion: Behind the eye globe.
• Preganglionc parasympathetic: from the oculomotor nerve through the nerve to

inferior oblique muscle.
• Postganglionic parasympathetic: from the ganglion to the eyeball through the

short ciliary nerves.
45


• Pterygo-palatine ganglion: In the pterygo-palatine fossa.
• Preganglionic parasympathetic: from the facial nerve in the petrous bone

through the great petrosal nerve which emerges from the petrous bone to
appear at the middle cranial fossa then enters the pterygoid canal
accompanied with the deep pterygoid sympathetic nerve to reach the
ganglion.
• Postganglionic parasympathetic: through the branches of the ganglion to the

lacrimal gland (zygomatic nerve to zygomaticotemporal to communicating
twigs with the lacrimal nerve), to the nasal mucosal glands and palatal minor
salivary glands.
• The great petrosal nerve also transmits taste sensation from the palate.
• Submandibular ganglion: on the lateral surface of the hyoglossus muscle.
• Preganglionic parasympathetic: from the nervus intermedius of the facial nerve

to the chorda tympani which exits from the petrous bone through the ptero-
tympanic fissure to join the lingual nerve.
• Postganglionic parasympathetic; to the submandibular, sublingual and tongue

minor salivary glands through the lingual nerve.
• The chorda tympani also transmits taste sensation from the anterior two-thirds
of the tongue.
• Otic ganglion: in the infratemporal fossa.
• Preganglionic parasympathetic; from the glossopharyngeal nerve through its

tympanic branch which arises just below the exit of the glossopharyngeal
from the jugular foramen. The tympanic branch enters the middle ear through
a canaliculus between the jugular and carotid foramen. The fibers to the otic
ganglion emerge from the petrous bone to the floor of the middle cranial fossa
as the lesser petrosal nerve. The lesser petrosal nerve passes through the
foramen ovale to reach the infratemporal fossa and join the otic ganglion.
• Postganglionic parasympathetic: from the ganglion to the auriculotemporal

nerve to the parotid salivary gland.
46


SALIVARY GLANDS
Parotid gland:
• Structure: mostly serous acini. Intra-glandular lymphoid tissue. Capsule of deep

cervical fascia.
• Relations:
o Superficially: skin, platysma, grear auricular nerve, preauricular lymph nodes

and deep fascia.
o Anteromedially: from lateral to medial is the masseter muscle, posterior

border of the ramus of the mandible and medial prerygoid muscle.
o Medially: The oropharynx.
o Posteromedially: the styloid process separating it from the carotid sheath

including the internal carotid artery, internal jugular vein and the last four
cranial nerves, the stylopharyngeus, styloglossus, stylohyoid and digastric
muscles.
o Upper pole: is insinuated between the external ear and the TMJ.
o Lower pole: is separated from the submandibular gland by the

stylomandibular ligament.
• Contents: The facial nerve and its terminal branches laterally, the retromandibular vein in
the middle and the external carotid and its two terminal branches medially.
• Neve supply:
• The preganglionic parasympathetic secretomotor from the lesser petrosal of the IX

cranial. The postganglionic fibers emerge from otic ganglion to join the auriculotemporal
of the mandibular.
• The preganglionic sympathetic vasomotor arise from the upper dorsal lateral horn
cells. postganglionic sympathetic relay in the cervical sympathetic chain and follow the
adventitia of the external carotid artery.
• The sensory nerve supply to the capsule through the great auricular "C2"
Parotid duct: crosses the masseter, pierces the buccinator and opens through the
vestibule opposite the upper second molar.
47


Submandibular salivary gland:
Structure: mixed acinar pattern. Capsule of the deep cervical fascia.
Relations:
• Superficially "inferolaterally": skin, platysma, marginal mandibular branch of the

facial nerve, anterior facial vein and submandibular lymph nodes.
• Laterally: the medial surface of the body of the mandible with the facial artery in
between.
• Medially: The anterior part is related medially to the myelohyoid muscle. The
posterior part winds around the posterior border of the myelohyoid and is related to
the hyoglossus muscle.
• Posteriorly: the facial artery grooves the gland or sink into it.
Nerve supply:
• The preganglionic parasympathetic secretomotor from the chorda tympani of the VII
cranial and join the lingual branch of the mandibular division of the trigeminal. The
postganglionic fibers emerge from submandibular ganglion.
• The preganglionic sympathetic vasomotor arise from the upper dorsal lateral horn
cells. postganglionic sympathetic relay in the cervical sympathetic chain and follow
the adventitia of the facial artery.
• The sensory nerve supply to the capsule through the transverse cervical "C2,3"
Submandibular duct: crosses the hyoglossus and has the lingual nerve lateral, below then
deep to it. It opens in the floor of the mouth at the anterior end of the sublingual fold of each
side of the frenulum.
Sublingual salivary gland:
Structure: only mucous.
Relations: oral mucosa above, sublingual fossa of the mandible laterally and myelohyoid
muscle inferiorly.
48

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Review notes in head and neck anatomy

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HEAD AND NECK

About the author:

Osama Hussein is a faculty lecturer at the surgery department of Mansoura University

© Osama Hussein, 2008

SUGGESTED REFERENCES ........................................................................................................................ 6

MANDIBLE AND MAXILLA............................................................................................................................ 7

THE SKULL ....................................................................................................................................................10

TEMPOROMANDIBULAR JOINT (TMJ) ......................................................................................................15

INFRATEMPORAL FOSSA ...........................................................................................................................18

FASCIA OF THE NECK .................................................................................................................................20

LYMPHATIC DRAINAGE OF THE HEAD AND NECK................................................................................22

TRIANGLES OF THE NECK .........................................................................................................................25

THE FACE ......................................................................................................................................................28

LIVING ANATOMY OF THE ORAL CAVITY ................................................................................................35

ANATOMY OF THE PHARYNX ....................................................................................................................37

CRANIAL NERVES ........................................................................................................................................39

TRIGEMINAL NERVE ....................................................................................................................................42

SALIVARY GLANDS .....................................................................................................................................47

Bony features of head and neck of interest to the dentist:

Anatomy of the infratemporal region:

Anatomy of the oral cavity and pharynx:

I- Identify the nuclear origin of both roots of the trigeminal nerve.

Arrangements of the fascial spaces and triangles of the neck:

I- Identify the investing, visceral and prevertebral fascial layers.

Lymphatics and spread of infections:

Facial nerve, artery, vein and muscles:

Anatomy of local anesthesia:

I- Describe the course of the alveolar nerves.

Anatomy of the temporomandibular nerve:

I- Identify the type of the joint.

• Textbook of oral and maxillofacial anatomy, histology, and embryology / edited by

• Illustrated dental embryology, histology, and anatomy / Mary Bath-Balogh, Margaret

• Skandalakis’ Surgical anatomy [electronic resource]: the embryologic and

• University of Pennsylvania interactive atlas.

• University of Minnesota self-test.

MANDIBLE AND MAXILLA

Key features of the Mandible

1. •The edentulous alveolar process.

Key Features of the Maxilla

MOST RELEVANT KEY FEATURES OF THE SKULL

Key features of the Sphenoid

• Medial pterygoid plate

Key features of the Temporal bone

Key Features of the Palatine bone

• Lesser palatine foramen

Norma lateralis of the Skull:

Pterygopalatine fossa communicates with:

1-Infratemporal fossa: through the pterygomaxillary fissure transmitting the maxillary

Normal Basalis Externa of the Skull:

compartments anterolateral and posteromedial to the septum respectively. Look at the

TEMPOROMANDIBULAR JOINT (TMJ)

• Mild Opening of the mouth: is mainly a hinge-type movement at the lower

• Mouth elevation: is produced by the masseter, temporalis and medial pterygoid

• Retraction: is mainly by posterior fibers of temporalis and elastic recoil of the

• Chewing: repetitive elevation and depression of the mandible accompanied by lateral

• Ligaments: The temporomandibular ligament is directed backwards and inferiorly from

• DVD atlas of human anatomy [videorecording] / Robert D. Acland. Baltimore

• Daniel M. Laskin: Temporomandibular disorders: the past, present, and future.

• Illustrated dental embryology, histology, and anatomy / Mary Bath-Balogh, Margaret J.

• Skandalakis’ Surgical anatomy [electronic resource]: the embryologic and anatomic