FASCIAS OF HEAD AND NECK

Presented by : Moderator :
Dr. Aditi Rapriya Dr. Surabhi V.
PG 1st Year Assistant Professor
Dept. of Oral & Maxillofacial Surgery Dept. of Oral & Maxillofacial Surgery
SGT College of Dental Sciences SGT College of Dental Sciences
 CONTENTS
• Introduction
• Skin
• Fascial layers
• Triangles of neck
• Fascial Spaces
• Classification of Fascial Spaces
• Drainage of Fascial Spaces
• Direction of Spread of infection
• Treatment of Fascial infections
• Conclusion
• References
 INTRODUCTION
• Fascia -layer of fibrous connective tissue beneath the skin that surrounds
and holds every organ, bones, muscles, vessels and nerves in place.

• There are several layers of fascia, which act to support and

compartmentalize the structures present.

• These fascial layers can broadly be divided into :

 Superficial Fascia - a subcutaneous tissue just under the dermis.
 Deep Fascia – deep connective tissue that surrounds muscles, bones, nerves
and blood vessels.
 Visceral Fascia – suspends organs within their cavities.
SKIN
 Structure of Skin

Superficial epithelial layer

(Epidermis)

Deep connective tissue layer

(Dermis)

Deep to the dermis, is hypodermis subcutaneous

tissue
(Superficial Fascia)
 Functions of Skin
1. Protection
- From abrasion, invasion, water loss, UV protection.
2. Vitamin D synthesis
- Epidermal keratinocytes when exposed to UV light.
3. Sensation
- Receptors for heat, cold, touch, pressure, vibration and pain.
4. Thermoregulation
- Thermoreceptors and sweat glands
5. Psychological and social functions
- Appearance and social acceptance
- Facial expression and non-verbal communication
FASCIAS
 FASCIA
Collection of connective tissue.

Superficial Fascia Deep Fascia

 Superficial Fascia
(Tela Subcutanea)
• Lies between the dermis and deep cervical fascia.
• Unites the skin to the underlying structures

• Surrounds Platysma and superficial vessels and nerves but does not contribute to
compartmentalization.
• Contains numerous structures :
• Neurovascular supply to skin
• Superficial lymph nodes
• Fat
• Platysma muscle
• Necrotizing Fascitis – infection of superficial fascia causing necrosis of
tissue in subcutaneous space.

Skin
+
Superficial Musculocutaneous
Superficial Fascia Aponeurotic System
+ (SMAS)
Platysma
 Platysma
• The superficial cervical
fascia blends with the
‘paper thin’ Platysma
muscle.

• It is a broad superficial
muscle which lies
anteriorly in the neck.

• It has two heads, which

originate from the fascia
of the pectoralis
major and deltoid.

• Supplied by cervical
branch of facial nerve.
 Deep Cervical Fascia
(Fascia Colli)

• Forms a collar around the neck.

• Lies deep to Platysma muscle in the interval b/w muscles, vessels and
organs of the cervical region.

• Condensed to form:
1) Investing layer
2) Pretracheal layer
3) Prevertebral layer
4) Carotid sheath
5) Buccopharyngeal fascia
6) Pharyngobasilar fascia
 1. Investing Layer
• Lies deep to the Platysma and
surrounds the neck like a collar.

• Forms the roof of the posterior

triangle of the neck.

• Encloses the
sternocleidomastoid and
trapezius, the two large
superficial muscles of the neck
on either side.

• Encloses two salivary glands :

Parotid and Submandibular
gland.
• Tracing the fascia upwards from the clavicle to the lower border of the
mandible , it divides into two layers.
 Superficial layer
 Deep layer

• Superficial layer - attached to the lower border of mandible and deep layer
attached to mylohyoid line.
Between the two layers the submandibular salivary gland and the lymph
glands are enclosed.
• The deep layer of the fascia after covering the parotid gland goes towards the base
of the skull.

• Between the angle of mandible and styloid process of temporal bone, fascia is
thickened to form the stylomandibular ligament.

• The investing layer encloses two fascial spaces.

1. Suprasternal space ( space of Burns)
2. Supraclavicular space
 2. Prevertebral Layer
• Lamina prevertebralis

• The prevertebral
fascia surrounds the
vertebral column and its
associated muscles; scalene
muscles, prevertebral
muscles, and the deep
muscles of the back.
• The anterolateral portion of prevertebral fascia forms the floor
of the posterior triangle of the neck. It also surrounds the
brachial plexus as it leaves the neck and subclavian artery as it
passes through the lower neck region – in doing so, it forms
the axillary sheath.
 3. Pretracheal Layer
• Middle cervical fascia/ Porter’s
Fascia/ Lamina pretrachealis
• Superiorly it extends upto the hyoid
bone.

• Inferiorly it extends into the thorax

and joins the fibrous pericardium.

• Laterally it fuses with the carotid

sheath and through this sheath it is
continuous with the investing layer of
deep cervical fascia.

•
Medially it divides and encloses
the thyroid gland.
It Has two portions :
Muscular layer
Visceral layer
 4. Carotid Sheath
• The carotid sheaths are paired structures on either side of the neck, which enclose an important
neurovascular bundle of the neck.

• The contents of the carotid sheath are:

i. Common carotid artery
ii. Internal jugular vein.
iii. Vagus nerve.
iv. Accompanying cervical lymph nodes.

• The fascia of the carotid sheath is formed by contributions from the pretracheal, prevertebral, and investing
fascia layers. The carotid artery bifurcates within the sheath into the external and internal carotid arteries.
 5. Buccopharyngeal Fascia
• It’s a delicate and
distensible layer of fascia
that covers the
constrictor muscles of
pharynx and buccinator
muscle.
• It stretches from the base
of the skull to the
esophagus.
 6. Pharyngobasilar Fascia
• Part of the middle layer of
deep cervical fascia that
attaches the pharynx to the
skull base.

• Originates between the

mucosal and muscular layers
of the pharynx.

• Sinus of Morgagni - a defect in

the anterior aspect of the
pharyngobasilar fascia,
containing the eustachian
tube and levator veli palatini
muscle
 Alar Fascia
• Forms a further division of
retropharyngeal space.

• It is a thin fibroareolar
membrane separating the
(anterior) true
retropharyngeal space from the
(posterior) danger space.
•
• Ventral component of the
deep layer of the deep cervical fa
scia
.

• location: between the visceral

and prevertebral fascia, dividing
 Danger Space
• Immediately posterior to retropharyngeal space and
immediately anterior to prevertebral space.

• Spread within the danger space tends to occur rapidly

because of the loose areolar tissue that occupies this region.
This spread can lead to mediastinis, empyema and sepsis.
 Visceral Layer
• Also known as subserous fascia.

• Suspends the organs within their

cavities and wraps them in layers of
connective tissue membranes.

• Each of the organs is covered in a

double layer of fascia; these layers are
separated by a thin serous membrane.

i. The outermost wall of the organ is

known as the parietal layer

ii. The skin of the organ is known as

the visceral layer. The organs have
specialized names for their visceral
fasciae.
 Brain - meninges
 heart - pericardia
TRIANGLES OF NECK
 Anterior triangle
• The anterior triangle is a
region located at the front of the
neck.

Borders
• The anterior triangle is situated
at the front of the neck. It is
bounded:
• Superiorly – inferior border of
the mandible (jawbone).
• Laterally – anterior border of
the sternocleidomastoid.
• Medially – sagittal line down
the midline of the neck.
• Investing fascia covers the roof of the triangle,
while visceral fascia covers the floor.

• The anterior triangle is subdivided by the hyoid bone,

suprahyoid and infrahyoid muscles into four triangles.
i. Carotid
ii. Submental
iii. Submandibular
iv. Muscular
 Carotid triangle
Boundaries:
• Superior – posterior belly of the
digastric muscle.
• Lateral – medial border of the
sternocleidomastoid muscle.
• Inferior – superior belly of the
omohyoid muscle.

Contents
• common carotid artery (which
bifurcates within the carotid triangle
into the external and internal carotid
arteries),
• internal jugular vein, and
• hypoglossal and vagus nerves
 Submental Triangle
• The submental triangle in
the neck is situated underneath
the chin.
• Contains the submental lymph
nodes, which filter lymph
draining from the floor of the
mouth and parts of the tongue.
• Boundaries
• Inferiorly – hyoid bone.
• Medially – midline of the neck.
• Laterally – anterior belly of
the digastric
• Floor - mylohyoid muscle
 Submandibular Triangle
• The submandibular triangle is
located underneath the body of
the mandible.
• Contains the submandibular
gland (salivary), and lymph
nodes. The facial artery and
vein also pass through this area.

• Boundaries :
• Superiorly – body of the
mandible.
• Anteriorly – anterior belly of
the digastric muscle.
• Posteriorly – posterior belly of
the digastric muscle.
 Muscular Triangle
• The muscular triangle is situated
more inferiorly than the subdivisions.
• It is a slightly ‘dubious’ triangle, in
reality having four boundaries.
• Contains some muscles and organs –
the infrahyoid muscles, the pharynx,
and the thyroid, parathyroid glands.

• Boundaries :
• Superiorly – hyoid bone.
• Medially – imaginary midline of the
neck.
• Supero-laterally – superior belly of
the omohyoid muscle.
• Infero-laterally – inferior portion of
the sternocleidomastoid muscle.
 Posterior triangle
• The posterior triangle of the neck
is an anatomical area located in the
lateral aspect of the neck.

• BORDERS
• Its boundaries are as follows:
• Anterior – posterior border of the
sternocleidomastoid.
• Posterior – anterior border of the
trapezius muscle.
• Inferior – middle 1/3 of the clavicle.
• The posterior triangle of the neck is
covered by the investing layer of
fascia, and the floor is formed by
the prevertebral fascia
 Subdivisions

• The omohyoid muscle splits the

posterior triangle of the neck into
two:
• The larger, superior part is
termed the occipital triangle.
• The inferior triangle is known as
the subclavian
triangle and contains the distal
portion of the subclavian
artery. It is also known as the
omoclavicular or supraclavicular
triangle.
FASCIAL SPACES
 Fascial Spaces

• Deep fascia encloses potential spaces into which infections of dental origin
can spread.

• Space is a misnomer ,there are no voids (SPACES) in the tissues in actual

reality.

• They do not exist in healthy individual but become filled during infections.

• Infection will always follow the path of least resistance ( bone density,
muscle attachment).

• Pathologically, secretions are noted with no tissue barrier= spread of

infections.
PTERYGOMANDIBULAR
SPACE

PAROTID
COMARTMENT SUBLINGUAL
SPACE

PARAPHARYNGEAL
SPACE
SUBMANDILBULAR
SPACE
Classification of Fascial Spaces
 IN RELATION TO HYOID
BONE

Face Suprahyoid Infrahyoid Involves entire neck

Buccal Submental Pre-tracheal Carotid space

Canine Submandibular Space Retro-pharyngeal
Parotid Sublingual Visceral space Space
Masticator Parapharyngeal Danger space
Periorbital Pre-vertebral
Space
 MODE OF
INVOLVEMENT

Maxillary Mandibular
Fascial Spaces
Spaces Spaces

•Canine •Submental •Submassetric

•Buccal •Submandibular •Pterygomandibular
•Infratemporal •Sublingual •Sup/deep Temporal
•Buccal •Lateral Pharyngeal
•Vestibular •Retropharyngeal
•Prevertebral
•Parotid Space
•Periorbital
 TYPES OF SPACES

Primary Spaces Secondary Spaces

• Canine • Submassetric
• Buccal • Pterygomandibular
• Superficial / Deep
• Submandibular
temporal
• Submental • Parapharyngeal
• Sublingual • Retropharyngeal
• Vestibular • Danger
• Prevertebral
• Periorbital
 Canine / Infraorbital Space
• Lies between levator anguli oris annd levator labii superioris muscles
superficial to canine fossa of maxilla.

• Usual dental source is maxillary canines or incisors.

CANINE
SPACE
 Buccal Space
• Lies between buccinator and skin,
location of the buccal pad.

• Infection presents with marked

cheek swelling.

• Usual dental source is premolars or

molars.
 Submandibular Space
• Swelling would be evident at submandibular triangle.
• Usual dental source is mandibular second or third molar
whose roots are BELOW attachment of mylohyoid to the
mylohyoid line.

MYLOHYOID MUSCLE
SUBMANDIBULAR SPACE SUBMANDIBULAR GLAND
 Submental Space
• Swelling would be evident at below chin between anterior bellies of
digastric.

• Usual dental source is mandibular incisor.

SUBMENTAL SPACE
 Sublingual Space
• Swelling would be evident in the floor of the mouth.

• Usual dental source is mandibular incisor, canine, premolar or first

molar whose roots are ABOVE attachment of mylohyoid to the
mylohyoid line.

SUBLINGUAL
GLAND

SUBLINGUAL
SPACE
 Vestibular Space
• Most common site for spread
of dental infections that break
out of alveolar bone.

• Lies between cortical bone and

mucoperiosteum.
 Periorbital Space
• Lies between orbicularis oris and orbital septum.

• Infection presents with redness and swelling of eyelid, may obstruct

vision.
 Submasseteric / Masseteric Space

• Lies between masseter and

ramus.

• Infection frequently involves

trismus.

• Usual dental source is impacted

third molars.
 Pterygomandibular Space
• Lies between medial pterygoid and mandibular ramus.

• Usual dental source is mandibular third molars or contaminated

needle.

PTERYGOMANDIBULAR
SPACE
 Para pharyngeal / Lateral Pharyngeal
Space
• Lies between masticator space anteriorly
and retropharyngeal space posteriorly.
• Usual dental source is mandibular third
molar.

PARAPHARYNGEAL SPACE
 Retropharyngeal Space
• Lies between buccopharyngeal fascia and alar fascia.

• Spans from base of skull to mediastinum.

 Parotid Space
• Infection presents with
medial bulge of lateral
pharyngeal wall, pain and
trismus.

• Usually not involved in

spread of dental infections,
but rather caused by
parotitis, sialolithiasis or
Sjogren’s syndrome.
 Carotid Space
• Potential space within the carotid
sheath.
• Also known as Visceral vascular
space.
• Lies :
 posterior to Parapharyngeal space
 Lateral to retropharyngeal space
 Medial to Parotid space and styloid
process.
• Mosher called carotid sheath as
Lincoln Highway of the neck
because all three layers of Deep
Cervical Fascia contribute to
carotid sheath.
APPLIED ANATOMY
 LUDWIGS ANGINA:

• It is a triangular swelling due to

infection in the submandibular
region.

• It is limited laterally by two halves

of mandible and posteriorly by
hyoid bone.

• This is because of the attachments

of investing layer of deep cervical
fascia to the base of mandible and
hyoid bone.
 MUMPS:

• Infection of parotid gland is painful due to thick and

strong fascia covering it.
 COLLAR STUD
ABSCESS:

• The deep cervical

lymph nodes are the
site of tuberculus
infection.
• Abscess penetrates the
deep cervical fascia and
form a swelling under
the skin.
• The thyroid gland and all thyroid
swellings move with deglutition
because the thyroid is attached to
the larynx by the suspensory
ligaments of Berry.

• The abscess present infront of

pretracheal fascia descends in the
superior mediastinum.

• The abscess present behind the

pretracheal fascia descends in the
superior mediastinum to the
posterior mediastinum.
• The carotid sheath is frequently
exposed in block dissection of the
neck during surgical remove of deep
cervical lymph nodes.
• The neck contains a series of compartments, which are bound by
tight fascia, and within the investing layer of deep fascia.

• The importance of these compartments is that infection tends to

spread within the spaces between the various fascial layers (for
example, an infection in the pretracheal space may spread inferiorly
into the superior mediastinum and lie anterior to the pericardium).
 DRAINAGE OF FASCIAL SPACES
• Canine, sublingual and vestibular abcesses = intra-orally

• Masseteric, pterygomandibular, buccal and lateral

pharyngeal space abcesses = combination of intraoral
and extraoral drainage.

• Temporal, submandibular, submental, retropharyngeal

and parotid space abcesses = extraoral incision and
drainage.
 DIRECTION OF SPREAD OF
INFECTION

• Infection from any tooth will spread along the path of

least resistance.
•
• It can perforate either the buccal cortical plate or lingual
or palatal cortical plate depending upon which is thinner.
TREATMENT OF FASCIAL SPACE
INFECTIONS
• Extraction or pulpectomy

• Incision and drainage (decrease bacterial load, increase

blood flow to site)

• Antibiotic coverage (if diffuse swelling, involved fascial

spaces, fever, tachycardia)
 CONCLUSION

• A clinician must have a working knowledge of all

information regarding signs, symptoms & history,
with results from clinical examination & tests to
obtain diagnosis resulting in a good treatment.
 REFERENCES
• Human anatomy by BD Chaurasia 5th ed
• Atlas of human anatomy by Frank H. Netter
• Lasts Anatomy – 12th ed
• Textbook of oral & maxillofacial surgery – Neelima Malik
• Textbook of oral & maxillofacial surgery – Laskin
THANK YOU