Skull and Face

1
Skull and Face

• Boonsirm Withyachumnarnkul, M.D., Ph.D.
• Department of Anatomy, Faculty of Science
• Mahidol University

2
Bony Landmarks of Skull and Face

• Vertex
• Superciliary arch
• Zygoma
• Mental symphysis
• Entrance to orbit
• Anterior nasal aperture

3
Three foramina vertically alligned

• Supraorbital foramen for supraorbital nerve
• Infraorbital foramen for infraorbital nerve
• Mental foramen ... for mental nerve

4
Muscles of Facial Expression

• Develop from the 2nd branchial arch, thus all are
  supplied by CN VII.
• Most are thin, originate from facial bones to
  insert on facial skin, except platysma, and are
  intermingled at their insertions.

5
Muscles of Facial Expression

• Muscle of the forehead frontalis, as part of
  the occipitofrontalis
• Muscles of the mouth
• Muscle of the eyelids
• Muscle of the nose
• Platysma

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Muscles of the Mouth

• Orbicularis oris
• Zygomaticus major
• Zygomaticus minor
• Levator labii superioris
• Levator labii superioris alaque nasi
• Buccinator
• Depressor anguli oris
• Depressor labii inferioris
• Mentalis
• Risorius
• Platysma

7
Muscles of the Mouth
8
Muscle of the Eyelids

• Orbicularis oculi
• Orbital part
• Palpebral part

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Buccal Pad Fat

• Between masseter and buccinator muscles
• Brown fat for heat generation, especially for
  children

10
Parotid Duct

• One finger-breadth below zygomatic arch
• Open into the mouth cavity (vestibule) at the
  level of the 2nd molar tooth (crown)

11
Facial Nerve

• Comes out from stylomastoid foramen
• Five branches
• Temporal
• Zygomatic
• Buccal
• Mandibular
• Cervical

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Facial Palcy

• No wrinkle of forehead
• Angle of mouth drops
• Sagging lower eyelid
• Other signs relating to malfunctions of
  structures innervated by facial nerve

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Trigeminal Nerve

• Sensory
• Ophthalmic division
• Maxillary division
• Mandibular division
• Motor .. To 1st branchial arch
• Muscles of mastication
• Messeter
• Temporalis
• Medial pterygoid
• Lateral pterygoid

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Arteries of the Face(rich, tortuous and highly
anastomosed)

• From external carotid artery
• Facial artery
• Superficial temporal artery
• Transverse facial artery
• From internal carotid artery
• supraorbital artery
• supratrochlear artery

15
Veins of the Face

• Two important veins
• Facial vein
• Retromandibular vein
• Facial veins have no valves
• Connection of facial veins, pterygoid plexus and
  cavernous sinus

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Lymph Drainage of the Face

• Submental lymph nodes
• Submandibular lymph nodes
• Parotid lymph nodes

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Scalp, Cranial Cavity and Venous Sinuses

• Boonsirm Withyachumnarnkul, M.D., Ph.D.
• Department of Anatomy, Faculty of Science
• Mahidol University

Head2.ppt in C (Mahidol)
18
Scalp

• Five layers of scalp
• skin
• dense subcutaneous tissue
• epicranial aponeurosis
• loose areolar connective tissue
• periosteum

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Scalp

• Clinical relevance
• infection spreading from loose areolar connective
  tissue, via emissary veins, to meninges-meningitis
  
• hematoma

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Skull Cap or Calvaria

• Suture
• coronal (frontoparietal)
• anterior fontanelle
• sagittal (interparietal)
• lambdoid (occipitoparietal)
• posterior fontanelle

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Skull Cap or Calvaria

• Three layers of skull cap
• outer table
• diploe
• inner table

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Cranial Fossae

• Anterior cranial fossa
• Middle cranial fossa
• Posterior cranial fossa
• Boundaries
• lesser wing of sphenoid
• superior border of petrous bone

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Anterior Cranial Fossa

• important landmarks
• crista galli cribriform plate of ethmoid
• sella turcica
• tuberculum sellae
• hypophyseal fossa
• dorsum sellae

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Middle Cranial Fossa

• important landmarks
• foramina
• superior orbital fissure
• foramen rotundum
• foramen ovale
• foramne spinosum
• groove for middle
• meningeal
• artery

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Posterior Cranial Fossa

• important landmarks
• grooves for transverse
• sigmoid sinuses
• foramen magnum

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Dura Mater

• Outer and inner layers
• position of the middle meningeal artery

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Dura Mater

• Falx cerebri
• Falx cerebelli
• Tentorial cerebelli and notch
• Diaphragmatic sellae

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Intradural Venous Sinuses

• Superior and inferior sagittal sinuses
• Straight sinus
• Transverse and sigmoid sinuses

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Intradural Venous Sinuses

• Cavernous sinus
• relationship among internal carotid artery, CN
  III, CN IV, CN V1 and CN VI
• venous connections
• clinical relevance
• thrombophlebitis

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Orbit and Eye

• Boonsirm Withyachumnarnkul, M.D., Ph.D.
• Department of Anatomy, Faculty of Science
• Mahidol University

31
Eye From the Outside

• eyelids
• palpebral fissure
• plica semilunaris
• caruncle
• lacrimal puncta
• cornea
• sclera
• conjunctiva
• bulbar
• palpebral

• Sty
• pterygium

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Bony Parts of the Orbit

• Entrance of the Orbit
• frontal bone
• zygomatic bone
• maxillary bone

• More Bones Inside
• ethmoid bone
• greater and lesser wing of sphenoid
• lacrimal bone

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Foramina of the Orbit

• optic foramen (canal)
• optic n.
• ophthalmic a.
• superior orbital fissure
• all other nerves
• superior ophthalmic vein
• inferior orbital fissure
• infraorbital n. a.
• inferior ophthalmic v.
• infraorbital groove foramen
• zygomatic infraorbital n.
• supraorbital notch foramen
• supraorbital n.

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Eyeball
35
Eyeball

• Muscles
• Extrinsic (Extra-ocular)
• Intrinsic

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Levator Palpebrae Superioris

• Supplied by CN III
• insert on the upper lid
• if paralyzed

ptosis
37
Extra-Ocular Muscles

• Superior Rectus
• Inferior Rectus
• Lateral Rectus
• Medial Rectus

• Superior Oblique
• Inferior Oblique

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Actions of the Extra-Ocular Muscles

• Around vertical axis
• medial or adduction
• lateral or abduction
• Around horizontal axis
• upward or elevation
• downward or depression
• Around antero-posterior axis
• medial rotation
• lateral rotation

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Superior Rectus
Make a 10-15 o with an AP axis
adduct
medial rotate
elevate
40
Inferior Rectus
depress
adduct
lateral rotate
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Medial and Lateral Recti

• Medial Rectus
• adduction

• Lateral Rectus
• abduction

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Superior Oblique

• depress
• abduction
• medial rotate

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Inferior Oblique

• elevate
• abduction
• lateral rotate

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Periorbita and Orbital Fat
45
Insertions of the Extra-Ocular Muscles
46
Nerves of the Extra-Ocular Muscles

• Oculomotor Nerve (CN III)
• supplies all except lateral rectus and superior
  oblique
• Trochlear Nerve (CN IV)
• superior oblique
• Abducens Nerve (CN VI)
• lateral rectus

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Oculomotor nerve (CN III)

• Superior Division
• levator palpebrae superioris
• superior rectus
• Inferior Division
• inferior rectus
• inferior oblique
• medial rectus
• not an extra-ocular muscle

48
Functional Tests of the Extra-Ocular Muscle

• Principle
• align the muscle axis with the eyeball AP axis
• contract the muscle
• e.g., for Superior Rectus
• abduct, first
• then, elevate
• Therefore, test for the superior rectus function
  is to abduct and elevate

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Parts of the Eyeball

• Three layers
• sclera
• choroid
• retina

• anterior chamber
• posterior chamber
• cornea
• iris
• ciliary muscle
• suspensory ligament
• lens
• hyaloid canal
• vitreous body
• aqueous humor

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Clinical Relevance

• lenticular cataract
• glaucoma
• Schlemns canal
• Myopia (near sightedness)
• hyperopia (far sightedness)
• presbiopia (old-aged sightedness)

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Blood Vessels of the Orbit Eyeball

• Ophthalmic
• Frontal
• anterior posterior ethmoidal
• supraorbital
• supratrochlear
• lacrimal
• central retinal

in the choroid layer
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Ophthalmoscopic Examination

• optic disc
• macula lutea fovea centralis
• retinal vessels in DM hypertension

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Veins of the Eyeball

• superior inferior ophthalmic veins
• drained to cavernous sinus
• connection to pterygoid plexus
• connection to facial veins

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Sensory Nerves of the Eyeball and Orbit

• frontal
• supraorbital
• supratrochlear
• lacrimal nerve
• nasociliary nerve
• anterior ethmoidal
• posterior ethmoidal
• infratrochlear

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Autonomic Nerves of the Eyeball and Orbit
Sympathetic
post-ganglionic sympathetic fibers
artery (ophthalmic a)
long ciliary n.
eyeball
iris (radial fibers)
Parasympathetic
pre-ganglionic parasympathetic fibers (in the
nerve to inferior oblique)
ciliary ganglion
short ciliary n.
Eyeball
ciliary muscle iris (circular fibers)
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Ciliary Ganglion
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Lacrimal Gland and Lacrimal Apparatus

• Lacrimal puncta
• lacrimal canaliculi
• lacrimal sac
• nasolacrimal duct
• opening into the inferior meatus of nasal cavity

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Parasympathetic Supply to the Lacrimal Gland
pterygopalatine ganglion
Preganglionic parasympathetic fibers
maxillary n
zygomatic branch
zygomatico-temporal branch
lacrimal n
lacrimal gland
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Eyelid

• upper lower eyelids
• conjunctiva
• palpebral fissure palpebral sac
• tarsal plates (superior inferior)
• tarsal muscle nerve (sympathetic n)
• tarsal gland ciliary gland Meibomitis sty
• attachment of levator palpebrae superioris

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Orbital Septum, Medial Lateral Palpebral
Ligament
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Submandibular Region, Nasal Region and Oral Cavity

• Boonsirm Withyachumnarnkul, M.D., Ph.D.
• Department of Anatomy, Faculty of Science
• Mahidol University

Head 6. ppt in C (Mahidol)
62
Submandibular Region

• Inferior border of mandible
• Suprahyoid muscles
• Including submandibular triangle
• Submandibular gland
• Nerves
• lingual
• hypoglossal
• mandibular branch of CN VII
• Blood vessels
• lingual
• facial
• Lymph nodes, submandibular lymph nodes

63
Submandibular Triangle

• Anterior belly of digastric muscle
• Origin, digastric fossa of mandible
• Nerve, nerve to mylohyoid (CN V)
• Posterior belly of digastric muscle
• Origin, mastoid notch
• Nerve, CN VII
• Inferior border of mandible

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Actions of Digastric Muscle

• Elevate hyoid bone
• Open jaw
• Raising floor of mouth for swallowing reflex

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Suprahyoid Muscles

• Digastric
• Mylohyoid
• Geniohyoid
• Hyoglossus
• Stylohyoid

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Mylohyoid Muscle

• Origin, mylohyoid line of mandible
• Insertion
• Body of hyoid bone
• Median fibrous raphe
• Nerve, nerve to mylohyoid (CN V)

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Geniohyoid Muscle

• Origin, mental spine
• Insertion, hyoid bone
• Nerve, C1 spinal nerve

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Hyoglossus Muscle

• From hyoid bone to side of the tongue
• Nerve, hypoglossal nerve

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Stylohyoid Muscle

• Origin, styloid process
• Insertion, hyoid bone (two slips)
• Nerve, CN VII

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Concerted Action of Suprahyoid Muscles

• Elevate floor of mouth for swallowing reflex

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Submandibular Gland

• superficial part
• deep part
• the two parts are separated by mylohyoid muscle
• mixed serous and mucous gland
• submandibular duct
• from deep part
• open at sublingual caruncle

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Anatomical Relationship

• Hypoglossal and lingual nerves are between
  mylohyoid and hyoglossus muscles
• Closed relationship between lingual nerve and
  submandibular duct

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Chorda tympani

• special sense (taste) from anterior 2/3 of tongue
• preganglionic parasympathetic fibers to
  submandibular and sublingual gland, via
  submandibular ganglion

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The Nasal Region

• Nostrils
• Vestibule
• Nasal cavity
• Choanae
• Nasal septum
• Cartilage, septal cartilage
• Bone
• perpendicular plate of ethmoid
• vomer
• maxillary palatine

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Lateral Wall of the Nasal Cavity

• Chonchae
• superior, part of ethmoid
• middle, part of ethmoid
• inferior, separate bone

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Lateral Wall of the Nasal Cavity

• Meatuses
• sphenoethmoidal recess, opening of sphenoidal
  sinus
• superior, opening of posterior ethmoidal air
  cells
• middle
• bulla ethmoidalis, opening of middle ethmoidal
  air cells
• hiatus semilunaris, opening of
• maxillary sinus
• anterior ethmoidal air cells
• frontal sinus, infundibulum
• inferior, opening of nasolacrimal duct
• common meatus

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Nerves of the Nasal Cavity

• Special sense, olfactory n. "olfactory mucosa"
• General sense, "respiratory mucosa"
• branch of nasociliary n.
• anterior ethmoidal n.
• branches of maxillary n.
• nasopalatine n.
• posterior superior lateral nasal n.
• posterior inferior lateral nasal n.
• Test of olfactory function

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Third Part of the Maxillary Artery

• superior alveolar a.
• posterior
• anterior, from infraorbital a.
• infraorbital a.
• descending palatine a.
• greater palatine a.
• lesser palatine a.
• sphenopalatine a.

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Blood Supply of the Nasal Cavity

• from sphenopalatine a.
• posterior lateral nasal br.
• posterior septal br.
• from ophthalmic a.
• anterior and posterior ethmoidal a

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Paranasal Air Sinuses

• Locations
• frontal sinuses
• ethmoidal air cells
• posterior
• middle
• anterior
• sphenoidal sinuses
• maxilary sinus
• Functions
• warm and humidify air
• resonance

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Maxillary Nerve

• out of the skull through foramen rotundum
• branches
• zygomatic n.
• zygomaticotemporal n.
• zygomaticofacial n.
• infraorbital n., out from the infraorbital
  foramen
• superior alveolar n. anterior, middle, posterior
• two small br. to pterygopalatine ganglion

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Pterygopalatine Ganglion

• In
• pterygopalatine br. from maxillary n., general
  sense
• nerve of pterygoid canal
• parasympathetic
• sympathetic
• Out
• pterygopalatine br. to maxillary n.,
  parasympathetic fibers to lacrimal gland
• pharyngeal n.
• greater and lesser palatine n.
• superior and inferior lateral nasal n.
• nasopalatine n

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Pterygopalatine Ganglion

• All the "out" branches supply
• submucosal gland, parasympathetic
• general sense
• lacrimal gland, parasympathetic

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Mouth Lips

• vestibule
• oral cavity proper
• nasolabial sulcus
• philtrum
• labial gland
• frenulum
• palatoglossal arch
• palatopharyngeal arch
• opening of parotid duct
• opening of submandibular sublingual ducts

85
The Teeth

• Types
• incisor, 2
• canine, 1
• premolar, 2
• molar, 3
• Nerves and vessels (to teeth and gingivae)
• alveolar
• superior (maxillary n. and a.)
• anterior
• middle
• posterior
• inferior (mandibular n., maxillary a.)
• nasopalatine (maxillary n. and a.)
• greater palatine (maxillary n. and a.)

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The Tongue

• sulcus terminalis
• foramen caecum
• papillae
• circumvallate
• fungiform
• filiform
• foliform
• lingual tonsil

87
Muscles of the Tongue

• Intrinsic
• longitudinal
• transverse
• vertical
• Extrinsic
• hyoglossus
• genioglossus (movement of tongue)
• styloglossus
• palatoglossus

88
Artery Nerves of the Tongue

• Artery
• lingual a.
• Nerves
• motor, hypoglossal n., except palatoglossus
  (vagus n.)
• sensory
• general, CN V, IX X
• special, CN VII (anterior 2/3) CN IX (posterior
  1/3), CN X

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The Palate

• Hard palate
• Soft palate, muscles
• tensor veli palatini (CN V)
• levator veli palatini (CN X)
• musculus uvulae (CN X)
• palatoglossus (CN X)
• palatopharyngeus (CN X)
• Clinical relevant
• openning of auditory
• tube
• test of CN X

90
Blood Supply of Palatine Tonsil (important for
tonsillectomy)

• from lingual a.
• dorsal lingual a.
• from facial a.
• tonsillar br.
• ascending palatine a.
• from ascending pharyngeal a.
• palatine br.
• lesser palatine a.