Anatomy for

oral and
maxillo-facial
surgery
 DEFINITION

“Oral & Maxillofacial Surgery is the

specialty that deals with the diagnosis and
surgical and adjuvant treatment of soft,
hard tissue and lesions and defects of the
oral and maxillofacial region.
”- Larry J. Peterson
 Maxillo-Facial Surgery
 The surgical specialty that deals with the
diagnosis and treatment of diseases of interest:
 Oral cavity
 Maxillary bones and maxillary sinuses
 Salivary glands
 Soft facial and cervical parts
 The only medical specialty that requires a
double license
 Order no. 1138 of 15/09/2004(4):

 Starting with the 2005 session of the residency competition

in this specialty, only the doctors and dentists will be
confirmed, who are enrolled in the 5th or 6th year of
training at the second faculty of dentistry and medicine,
respectively. , as well as those who have two licenses, a
doctor and a dentist.
Order no. 1142/2007:

 On the approval of the Nomenclature of medical, medico-

dental and pharmaceutical specialties for the healthcare
network

 From the 2009 session of the "Oral and Maxillofacial

Surgery" residency competition, only physicians with two
bachelor's degrees in medicine and dentistry will be
confirmed as residents.
Particularity of the territory
MORPHOLOGICAL FEATURES:

 Thin,smooth,mobile skin
 Fascia superficialis-absent
 Crossed subcutaneous tissue of the skin muscle
 The jaw and mandible are characteristic of this territory
 Maxillary bones:- present in the teeth

- the fibromucosa is adherent

intraorally
- present in the intraosseous canals
 Adipose tissue allows communication between spaces

and lodges
 Muscle mass is not important
 Rich vascularity
 Face and neck features ditches,folds,dimples and Langer
lines
Particularities of the territory
MORPHOLOGICAL FEATURES:

 Adipose tissue helps to achieve the physiognomic

functions of the face
 There is extensive communication between different
regions through the fat cell tissue
 Complex and rich innervation
 The main salivary glands, as well as the accessory ones,
give particularity to this territory, increasing its complexity.
 The salivary glands and their ducts increase the complexity
of the territory
 Mucosa lining the cavities and cervico-facial ducts
 Communicates widely with the outside
- is septic
- resists well to exogenous infections
 The face plays a role in interpersonal relationships

 The morphological and aesthetic expression of the face is one of

its main functions

 Maxillofacial lesions have repercussions on social, professional or

family relationships.

 The psychological problems of patients with dento-maxillofacial

damage are complex.
 Particularities of the territory
Functional features:

• Chewing

•Deglutition

•Breath

• Phonation

• Occlusion of the orifices (buccal,

eyelid)

• Functions of some sensory organs

• Physiognomic function
The limits of the maxillofacial territory
Head and neck regions
 1. frontal region
 2. parietal region
 3. occipital region
 4. temporal region
 5. nasal region
 6. labial region
 7. mental region
 8. palpebral region
 9. genian region
 10. masseter region
 11. parotid region
 12. submental region
 13. submandibular region
 14.lateral cervical region
 Frontal region

Boundaries

 Superior: coronal suture

 Inferior: a line that joins the

temporal line of the frontal scale
with the root of the nose and
passes through the fronto-
zygomatic suture, the supraorbital
rim and the fronto-nasal suture

 Lateral: Temporal lines of the frontal

squama
 Layers

 Skin

 Subcutaneous cellular tissue SCALP

 Epicranial aponevrosis
 Layers
Muscular plane:
 Orbital part of orbicularului oculi
 m. depressor supercili
 m. corugator supercili
 m. procerus
 Frontal part of
m. occipitofrontalis
 Layers

 Periosteum
 Bone – Frontal squama
 Frontal sinuses – they open into the middle nasal
meatus through the frontal ostium
The supratrochlear vasculonervous package

-Supratrochlear artery
Branch of opthalmic artery
- Anastomosis:
- Supratrochlear artery
- Supraorbitary artery
- Supratrochlear nerve
-upper eyelid skin in 1/3 average
-the root of the nose
- Supratrochlear veins – drain to
angular vein.
 The supraorbital vasculonervous
package
- Supraorbitary artery– branch of Ophtalmic artery
- Anastomosis:
- Supratrochlear artery
- opposite Supraorbitary artery
- frontal branch of superficial temporal artery
- Supraorbitary nerve branch of frontal nerve
- medial branch of frontal region skin
- laterally branch for superior eyelid
- Supraorbitary vein– drain to angular vein
The temporal vasculonervous package

- A- frontal branch of superficial temporal artery

- V- superficial temporal vein
- N- Frontotemporal branch of facial nerve
 Temporal Region
Limits:
 Superior: Superior Temporal line

 Inferior: passing horizontal plane

through the zygomatic arch and on above CAE

 Anterior:
-posterior face of zygomatic process of frontal bone
-posterior face of frontal process of zygomatic bone
-temporal face of zygomatic bone
-temporal line of frontal squama

 Posterior: Supramastoid crest and temporal line

Layers
 Skin

 Subcutaneous plane - lax connective tissue in which are found :

 Muscles– auriculary anterior and superior
 Temporal superficial artery (terminal branch of ACE)
 Temporal superficial vein - descends into the parotid gland
and forms with the maxillary vein, the retromandibular vein
 Auriculotemporal nerve – sensitive branch of mandibular
nerve
 Temporo-frontal branch of Facial Nerve
 Lymphatic vessels – parotid ganglions (superficial and deep)
 TMJ SURGERY
 Lucy Frey’s Sdr
 mumps disease
- Aponevrotic plane- Lateral portion of epicranial aponeurosis
- Fascial plane – Temporal Fascia
 Muscular plane– temporal muscle
 Periosteum plane

Bone plane
-lateral portion of calvary
- extern face of temporal squama
-extern face of parietal bone
-temporal face of great wing of
sphenoid bone
-temporal face of frontal squama

Suture – H – pterion
 Nasal Region

Limits

 Superior: frontal-nasal suture

 Inferior: the line passing trough posterior margin of mobile nasal

septum

 Lateral: orbitary-nasal ditch and genian nasal ditch

 Layers

 SKIN - thin and mobile above the periosteum (upper);thick

and adherent to the top and wings of the nose

 Subcutaneous plane - poorly represented lax connective

tissue
Muscular plane

 M.procerus

 M.nasalis

 M. levator labii superioris

alaeque nasi
Periost / perichondrium

- blade of connective tissue that covers bones and

cartilage
Osteo-cartilaginous plane

 Bones

 the frontal process of the

maxilla
 nasal bones
 anterior nasal spine
 Cartilage:

 septal cartilage;
 major wing cartilage;
 minor wing cartilage;
 accessory cartilage.
 Vascular supply:

- alare branches and

septal (from Facial
artery)

- dorsal nose artery

(from ophthalmic)
 The lateral wall of the nasal fossae
has the prominences of 3 horns,
separated by ditches, which lead to
the 3 mines

 Superior- posterior ethmoid cells

 Middle
- frontal sinus ostium
- maxillary sinus
- anterior ethmoid cells

 Inferior- lacrimo-nasal canal

!!! Ophtalmic veins - infections
can be complicated by cavernous sinus
thrombophlebitis
 Kiesselbach vascular spot - antero-inferior part of the nasal septum - site of the
anterior epistaxis

 Anastomoses are: anterior ethmoidal artery (ophthalmic a.); sphenopalatine a., great
palatine a. (maxillary a); the labial sup artery (from the facial a)
Labial Region

 Limits

 Superior: curved line with the lower concavity passing through

the posterior margin of the mobile portion of the nasal septum
 Lateral: vertical line descending 1 cm laterally from the mouth
corners
 Inferior: labial-chin groove
 Layers

 Skin plan– thick and adherent to the underlying muscle bundles

due to muscle insertions on the deep face
 Muscular plan

 Orbicularis oris
 Levator labii superioris alaeque
nasi
 Levator labii superioris
 Zygomaticus major
 Zygomaticus minor
 buccinator
 risorius
 Depresor anguli oris
 Depresor labii inferioris
 Glandular Plan
 Mucosal Plan – is part of the mucosa of the oral cavity
 Arterial Supply – labial artery(facial artery)

 Labial vein→facial vein

 Lymphatics
-submandibular lymph nodes
-submental lymph nodes (sometimes the drenaige is directly into the deep
cervical ganglions)
 the anastomoses between the facial
vein, the ophthalmic vein and the
pterygoid plexuses explain the
possibility of the spread of infections
starting from the nasal pyramid or the
upper lip at the level of the cavernous
sinus.
 innervate motor - from nerveVII

 sensitive - upper lip branches from

infraorbitary nerve for upper lip and
lower lip branches from mental nerve
for chin guard and lower lip
 Mental Region
Limits

-superior: labial-chin ditches

-inferior: margin of the mandibular body
-lateral: vertical line 1 cm wide extern the corners of the
mouth
Layers

 Skin plan

 Subcutaneous plan
- poorly represented
-contains the upper fibers of the
platysma muscle
Muscular plan
 Mentalis Muscle
 Depresor labii inferioris
 Depresor anguli oris

Bone plan– Anterior arch of

mandible
 The vessels and nerves of the region the chin:

 vasculonervous mental package

 branches from inferior labial artery

 mandibular marginal branch of the facial nerve - for mimic

muscles

 Lymphatic vessels, wich drain into the submental and

submandibular lymph nodes.
 Mental foramen- mental
vasculonervous package

 Mental nerv - mucosa and skin

of the lower lip, the skin of
mental region, the mucosa of
the buccal vestibule inf near
PM1 and front teeth

 Mental artery - for the soft

parts of the region
 Position of mental groove
-in the cranio-caudal sense it varies according to age. In the
dentate adult, it is ½ at the distance between the alveolar edge and
the basilar edge of the mandible.

-in children it is closer to the basilar edge in edentulous it can be

located right on the alveolar ridge In the sagittal sense.

- the mental groove is in the right PM1 or between PM1 and PM2
In edentulous, the distance between the margin of the masseter
muscle and the chin symphysis can be used as a landmark, the
mental groove being located at ½ this distance.
Genian Region
Limits

 Anterior: naso-genian ditch and si vertical line

descending at 1cm lat of labial commissure

 Posterior: anterior margin of masseter

 Superior: lower orbital rim

 Inferior: the basilar edge of the mandible

Infraorbitaly region– supero-medial
Zygomatic region – supero-lateral
 Layers

 Skin plan

 Subcutaneous plan- discontinuous due to the skin insertions of the

mimic muscles
 Superficial muscular layer:

 Platysma
 Orbicularis oculi
 Levator labii superioris and
alaeque nasi
 Levator labii superioris
 Zygomaticus major si minor
 Risorius
 Depresor anguli oris
 Deep Muscular Plane:

 Levator anguli oris

 Buccinator
 Buccal space – between the 2
muscle planes

 The fatty body of the cheek

 Stenon parotid duct
 Arteries of the region :
-transvers artery
-infraorbital artery
-buccal artery
-facial artery
 Lymph nodes
-genian lymph nodes
-submandibular lymph nodes
-superficial parotide lymph nodes
 Masseter region

Limits

 Anterior: anterior margin of masseter muscle

 Posterior: posterior margin of vertical ramus of
mandible
 Superior: zygomatic arch
 Inferior: basilar edge of mandible
 Layers
Skin
Subcutaneous plan- contains:
 superficial blade of the cervical fascia
 branches from Great Auricular nerve
 branches from auriculo-temporal nerve
 fibers from Risorius, major and minor
zygomatycus, Platysma
 Anterior extension of the parotid gland with:
-transverse vessels of the face
-zygomatic and buccal branches from n VII
-Stennon
 Masseter fascia
-is inserted on the bony elements of the boundaries of the
region
-together with the vertical branch of the mandible it forms
the masseter lodge

 Muscular plane – maseter muscle

 Bone plane - the vertical branch of the mandible

 Parotid/Retromandibular Region
Limits
 Anterior: posterior margin of mandibular
ramus
 Posterior: mastoid process and anterior
margin of SCM
 Superior: ECA
 Inferior: the horizontal line that continues
back the basilar margin of the mandible
 In depth - the region extends to the
styloid process and the wide face of the
pharynx
 Layers

 Skin plan- thin and mobile

 Subcutaneous plan- contains

platinum fibers and nerve threads
from the cervical plexus (great
auricular

 The fascial plan- the superficial

blade of the cervical fascia, which
is called the parotid fascia

 Deep plan- parotid gland

Mandibular-vertebral-pharyngeal space

 divided by the deep blade of the parotid fascia into:

-the glandular space-occupied by the parotid gland

-subglandular space (latero-pharyngeal)
 The subglandular / latero-pharyngeal
space is divided by the stylian
diaphragm (formed by the stylian
bouquet and the stylopharyngeal
aponeurosis) into:

-retrostyloid space
-prestyloid space
 Prestyloid space:

-medial and lateral pterygoid muscles

-mandibular nerve with its branches
-maxillary artery
 Retrostyloid space:

-the vascular-nervous package of the neck

- IX, XI, XII nerves
-superior lymph nodes of sympathic
-cervical lymph nodes
 Villaret Syndrome

 ipsilateral and simultaneous

paralysis of the last four pairs of
cranial nerves (IX, X, XI, XII)
and Claude Bernard-Horner
syndrome (caused by paralysis
of the cervical sympathetic
nerves)
Through the parotid gland pass:

 ECA with its terminal branches

 EJV
 Superficial and deep parotid
lymphatic vessels
 Auriculo-temporal nerve
 VII nerve- divides the gland into
a superficial and a deep lobe
 Arterial irrigation of the region:

 transverse of the face artery

 anterior and posterior auricular artery
 the veins flow into the retromandibular vein
 the lymph vessels drains into the parotid and deep lymph
nodes
Innervation- auriculotemporal nerve, pericarotid
sympathetic plexus extern
 Oral cavity
 It is a deep and median region, located under the nasal cavity, above
the suprahyoid region and the anterior pharynx
 Represents the initial segment of the digestive tract

LIMITS

 anterior- Labial region

 lateral- Genian region
 dento-alveolar arches divide the oral cavity into 2 compartments:
-the buccal vestibule
-the oral cavity itself
The buccal vestibule:

the horseshoe-shaped space

with the post concavity,
delimited on the one hand by
the lip and cheeks, on the other
by the dento-alveolar arches
 Contains:
 anesthesia of infraorbitar nerve,
postero-superior alveolar nerve, buccal
nerve, mentalis nerve
 the access path for the surgical
approach of the maxillary sinus
 Stenon channel opening hole - near
second superior molar.
 Retromolar space - delimited
between third inferior molar
and pterygomandibular fold
-is communication between the
buccal vestibule and the oral
cavity itself
-through this space we can insert
the probe for feeding patients
with trismus or ATM ankylosis
- Spix anesthesia
 The oral cavity itself

Limits

-Anterior and lateral: dento-alveolar arches

-Superior: palatal vault

-Posterior: oropharyngeal isthmus

-Inferior: buccal floor and tongue

 Dental arches
 formed by the alveolar processes
of the maxillary and the mandible
covered by the gums.
 Teeth-the man are difiodont and
has 2 dentitions-temporary
with20 teeth and permanent
with32 teeth)
 Hard periodontium - dental
alveolus and root cementum
 Soft periodontium - gum and
alveolodental ligament
 Oral floor
 M.geniohyoid

 M.mylohyoid

 M.digastric– Anterior Portion

Sublingual Region
 Lingual brake mucosa, sublingual
envelopes, sublingual caruncles
with Wharton groove opening holes
 The sublingual lodge contains: the
sublingual gland with its excretory
canal, the extension of the
submandibular gland with the
Wharton's canal, the sublingual
vessels, lingual nerve
 Tongue
 The base of the tongue - the
portion fixed to the
surrounding organs
 The body of the tongue - the
free portion, which is found on
the floor of the oral cavity
Structure of tongue
Osteofiber skeleton

Muscle

Mucous part
Osteo-fibrous skeleton
 Hyoid bone

 Hyoglossian membrane - stretched from the hyoid bone to the

depth of the base of the tongue

 Lingual septum - arranged sagittally between the two halves of

the body of the tongue
Extrinsec muscles
 Origin – bone
 Genioglos muscle
 Hioglos muscle
 Stiloglos muscle
 Palatoglos muscle
 Faringoglos muscle
Intrinsec muscles
Located entirely in the tongue
 longitudinal superior muscle -
under the mucosa of the dorsal face
of the body of the tongue
 longitudinal inferior muscle -
between genioglossus and
hyoglossus, from the base to the tip
of the tongue
 Transverse muscle - arranged
transversely in the whole mass of
the body of the tongue
 Vertical muscle- from the dorsal to
the ventral face
 Lingual Mucosa
 Circumvallate papillae -
arranged in a "V" shape

 Fungiform papillae - on
the entire dorsal face

 Foliated papillae - in the

posterior part of the dorsal
face of the tongue
 Vascular supply
 Artheries
- Lingual artery
- Palatine ascending artery
- Pharyngeal artery

 Veins– from lingual vein

 Motor Inervation:
-Facial – stiloglos, palatoglos
-Hipoglos
Sensitive innervation:

 Lingual

 Glosopharyngeal

 Larynx sup
 The upper wall of the oral
cavity
 Plane of the palatine mucosa -
retroincisive papilla

 Glandular plan - salivarygland

accessories

 Bone plane - palatal processes of

the jaws and horizontal lamellae of
the palatal bones

 Large palatal orifices

Vascular supply:

 palatine descending artery

 sphenopalatine artery


 Veins - same the arteries

 Innervation: Great Palatine nerve and Nasal-Palatine nerve

 Neck
Limits:

 Superior:
 -basilar margin of mandible
 -base of the mastoid process
 -supine nuchal line
 -external occipital protuberance
 Inferior:
 -jugular notch of the sternum
 -upper face of the sternoclavicular joint
 -clavicle
 -horizontal line passing through C7
SCM divides the cervical region into 2
triangles :

-anterior- delimited by the anterior edges

of the SCM and the basilar edge of the
mandible

-lateral - delimited by the anterior margin

of the trapezius, the posterior margin of
the SCM and the average 1/3 of the
clavicle
Anterior Δ :
 It is divided into 2 ½ by a midline that connects the
chin symphysis with the jugular notch
 The submental region

Limits:

 Basilar portion of mandible

 Anterior portion of dygastric muscle

 The base of hyoid

Layers:

 Skin

 Subcutaneous cellular tissue - the anterior fibers of the platysma

 Superficial blade of the superficial cervical fascia Interdigastric

plane - contains the median ridge on which

 The anterior mylohyoid fibers and submental lymphatic ggl are

inserted
 Submandibular region
Limits:

 Anterior: anterior belly of

digastric

 Posterior: posterior belly of

digastric

 Superior: basilar margin of the

mandible
Layers

 Skin

 Subcutaneous cellular tissue - in which platysma

muscle fibers, a.submental branches, cervical
branch of VII nerve are found

 The superficial blade of the cervical fascia which

doubles at this level into 2 blades, which delimits
the lodge of the submandibular gland.
In the submandibular lodge are
also found:

 facial vein and facial

artery,located deep of the
submandibular gland


 Subglandibular lymphatic gg

 XII nerve

 Lingual nerve
 Carotid trigone region
Limits

 Antero-superior: belly post.digastric

and stylohyoid muscle

 Posterior: front edge of SCM

 Superior .omohyoid muscle

Layers

 The skin - thin and mobile

 Subcutaneous cellular tissue

 The superficial blade of the cervical fascia - which doubles at the anterior
margin of the SCM, forming a sheath for this muscle Vascular-nervous
package of the neck (CCA , IJV, n.X)

 Ggl deep cervical lymphatics

 The cervical sympathetic chain

 XII NERVE

 The external branch of the accessory

 This region the surgical
discovery and ligation of ACE
is made, using as main
landmark thyroid superior
arthery- Farabeuf triangle
(trunk TLFF, VJI and NXII
with posterior belly of the
digastric)
 The presence of the sinus
and the carotid glomus
make this region an
important reflexogenic
area
Extern carotid artery
 At the upper edge of the
thyroid cartilage
 Branches:

 Tiroidian artery
 .Pharyngian ascending
artery
 Lingual artery
 Facial artery
 Occipital artery
 Post.Auricular artery
Terminal Branches:

 Intern Maxillary artery

 Temporal Superficial artery

Cranial Nerves
Olfactory nerve
Optic nerve
 Oculomotor nerve

 Superior rectus muscle,

 Internal rectus muscle
 Inferior rectus muscle,
 Inferior oblique muscle,
 Levator palpebrae muscle
 Parasympathetic innervation
Ciliar muscle and sphincter
of the pupil
Trochlear nerve
 Superior oblique muscle
Trigeminal nerve

SENSITIVE- SOFT FACIAL AND

MUCOUS MEMBRANES
EXCEPT PHARYNGEAL
MUCOSA AND TONGUE BASE
(1/3 POSTERIOR)
•MIXT NERV

MOTOR - OF THE MOBILIZING

MUSCLES OF THE MANDIBLE.
Abducens nerve (extern
oculomotor nerve
 It exits the skull through the upper orbital fissure
 It innervates the right extern muscle
Facial Nerve
 Mixed nerve (motor,
sensory, parasympathetic
vegetative)
motor
Sensory nerve
vegetative
 In the parotid gland, the facial nerve bifurcates into the
temporo-facial trunk and the cervico-facial trunk
 Other ways of division: 3 trunks or intraparotid plexus
Temporo-facial trunk
 Temporal branches Zygomatic branches
 Upper mouth branches
 Cervico-facial trunk
 Lower mouth branches
 Mandibular marginal branch
 Cervical ram
Temporal Branches
Zygomatic branches
Buccal superior branches
Buccal inferior branches
Ramul marginal mandibular
Cervical Branches
Acoustic vestibular nerve
The glossopharyngeal nerve
Motor- stilopharyngeal muscle

Sensitive - amygdala lodge, laryngeal mucosa, eardrum,

Eustachian tube, carotid sinus

Sensitive-sensory - taste sensitivity 1/3 of the tongue

Parasympathetic vegetative- parotid gland

Vagus nerve
 Sensitive - the skin of the external acoustic meatus, the
mucosa of the larynx, pharynx, heart, abdominal viscera
 Motor - innervation of the muscles of the pharynx, soft
palate, larynx (EXCEPT M. STILOPHARYNGIAN)
 Sensitive-sensory - the gustatory sensitivity of the base of
the tongue and epiglote
 Vegetative - smooth muscles of the trachea, bronchi,
gastrointestinal tract, regulates heart rate
Accesory (Spinal) Nerve
hypoglossal nerve