CAPÍTULO

Head
F. Paulsen
Sobotta Atlas of Human Anatomy, Vol. 3, 8, 1-96

The Head – Leading from the Top

The skeleton of the head (caput/cephalon), i.e. the skull (cranium), consists of two parts: the facial bones
(viscerocranium) and the skull (neurocranium). The border between the two – the roof of one and the floor
of the other – is the base of the skull, which lies roughly in an oblique plane defined by the eyebrows, the
external opening of the outer ear canal and the base of the occiput.

Skull Cap (Calvaria) and Scalp

The highly arched calvaria (skull cap, cranial cap) forms a longitudinal oval dome over the cranial base
and protects the cranial cavity, in which the brain (cerebrum) surrounded by hard and soft meninges floats
in the cerebrospinal fluid (CSF). The calvaria is divided in frontal, parietal, temporal, and occipital regions
formed by identically named bones (frontal, parietal, temporal and occipital bone).

The skin of the calvaria is tough (“scalp”) and firmly adherent to a flat tendon, which spans from the
forehead to the occiput. This tendon (epicranial aponeurosis) is part of the occipitofrontalis, a mimic muscle
that raises eyebrows and wrinkles the skin of the forehead horizontally. Skin and tendon are movable on the
skull cap and can be relatively easily lifted off and removed as the scalp. Vascular injuries of the scalp can
lead to a severe but usually not-life threatening bleeding.

Skull Base
The base of the skull forms the roof of the two orbits and the nasal cavity, but also the roof of the throat
(pharynx, reaching up to the base of the skull) and the base of the occiput which articulates at the occipital
foramen (foramen magnum) with the first cervical vertebra. Numerous foramina, canals, and fissures cover
the cranial base and serve as passageways for many nerves and blood vessels. At the bottom side of the skull
base, pointing towards the viscerocranium, numerous processes, spines, and notches are present, to which
muscles and ligaments are attached. The upper side of the skull base, the floor of the neurocranium, is less
irregular and resembles terraces on three floors: the top floor, the anterior cranial fossa, is positioned above
the orbits. One step down, the middle cranial fossa is located at the level of the temporal bones. The last
step leads down into the posterior cranial fossa with the foramen magnum.

Facial Bones and Cavities

The largest facial bone, the maxillary bone (maxilla), is placed in the center of the viscerocranium. The
maxilla forms the floor of the orbits most of the sidewalls of the nasal cavity, the anterior part of the palate,
and carries the maxillary row of teeth. Like many other bones of the skull, the maxilla is “pneumatized”, i.e.
it is hollow and filled with air which is drawn from the nasal cavity (maxillary sinus, paranasal sinuses).
Besides the maxilla, half a dozen other smaller bones are involved in the construction of the
viscerocranium.

Breathing, smelling, tasting, chewing, swallowing, speaking, seeing, and being seen – these are the tasks of
the organs that are supported and protected by the viscerocranium.

The eyes and their auxiliary apparatus (visual system, → p. 98 ) are responsible for vision. Being seen is the
responsibility of the facial muscles. The permanent activity of these muscles, which do not control bones but
the facial skin, is responsible for the formation of wrinkles.
The olfactory sense is up to the nose, even though it only performs it with its smallest part, the olfactory
epithelium at the roof of the nasal cavity under the base of the skull. The outer cartilage-framed nasal
vestibule and the far more spacious bony inner nasal cavity serve for breathing: Through the inner nostrils
(choanae), the nasal cavity opens behind the throat (pharynx) which in turn communicates much more
caudally with the larynx and the windpipe (trachea).

Biting, chewing, talking, tasting, and swallowing are the functions of the oral cavity and the accompanying
organs. Similar to the nose, the oral cavity also has a vestibule, the space between lips and cheeks on one
side and the teeth on the other side.

Behind the teeth lies the larger oral cavity proper which is almost completely filled by the tongue at a closed
bite. At its posterior aspect, the oral cavity opens towards the pharynx and, at the price of choking, the
respiratory tract and ingestive tract cross here. The roof of the mouth, the palate, also forms the floor of the
nasal cavity. In the front, the palate is rigid and bony, while dorsally towards the pharynx it becomes soft,
flexible, and muscular. The uvula dangles from the soft part of the palate. The floor of the mouth, which is
surrounded by the movable mandible and which carries the tongue, is made of muscle plates. During speech
almost all of these structures act together (along with many other structures), whereby the nose is used as
an additional resonator.

Two pits of the facial skeleton are important: If one removes (first imaginary, later on in reality during the
dissection sessions) the ascending bony branch of the mandible (ramus of mandible), which leads to the
temporomandibular joint, one enters the soft tissues of the lateral aspect of the head from “behind the
cheek” and enters a space that is referred to as the infratemporal fossa. Positioned in this region are
masticatory muscles (medial and lateral pterygoid) and several branches of nerves. In addition, the terminal
branches of the large external carotid artery lead towards the center of the viscerocranium.

In the direction of the orbit, the infratemporal fossa extends further inwards and cranially into a wider
space, the pterygopalatine fossa. It is essential to locate this cavity during dissection and its contents and
multiple pathways are important to remember. This cavity is a “key distributor” for vessels and nerves of
the viscerocranium. Since it is hidden and its anatomy is extremely complex, all anatomists adore it and like
to examine students on it.

Ailments and injuries of the head are frequent events; however, diseases affecting the skull base are
rare. Common to all is the fact that they are often life-threatening. Since the head is an anatomically
complex system, consultation by a variety of medical experts is required to ensure optimal care of the
patient. This team of experts includes medical disciplines like otolaryngology, head and neck surgery,
neurosurgery, oral, dental, facial and plastic surgery, ophthalmology, radiation therapy, and
diagnostic radiology and neuroradiology. Some patients with a severe head-related ailment (e.g.
unclear headache or impaired blood perfusion in a region of the brain stem resulting in vertigo and
nausea) have experienced an odyssey of referrals from one doctor to the next before encountering the
one physician or, even better, a team of medical experts who identify the problem and are able to help
this patient. As a response to this, some university medical centers now offer a co-ordinated,
multidisciplinary team approach to provide quality treatment and follow-up for such patients. Thus,
therapeutic strategies are discussed and co-ordinated among the members of the different medical
disciplines involved in each particular case in order to provide the most optimal patient care and allow
for a speedy recovery of the patient.

Clinical Remarks

→ Dissection Link

The dissection of the superficial facial region at the lateral sagittal plane of the head (head in a lateral
position) is showing the facial arteries and veins, muscles of facial expression, all branches of the facial
nerve, and the peripheral branches of the trigeminal nerve.
The dissection of the deep facial region includes the removal of the parotid gand, the presentation of the
parotid plexus (facial nerve [VII]), the dissection of the retromandibular fossa, the representation of all four
masticatory muscles, and the demonstration of the course of the maxillary artery up to its terminal
branches, as well as the preparation of the temporomandibular joint with presentation of the articular disc
and identification of the chorda tympani.

Dissection of the midsagittal planes of the head (head in medial position): The dissection of the nasal
septum with its cartilaginous and bony parts as well as the olfactory nerves and the nasopalatine nerve is
followed by the removal of the nasal septum and the presentation of the lateral nasal wall with openings of
the paranasal sinuses and the nasolacrimal duct. The pterygopalatine fossa is opened and its contents are
displayed. Finally, the sphenopalatine artery at the sphenopalatine foramen is located, followed by the full
dissection of the oral cavity with representation of the submandibular and sublingual glands, lingual,
hypoglossal, and glossopharyngeal nerves, as well as the dissection of the palatal muscles beneath the
auditory tube cartilage, and of the tonsillar fossa.

EXAM CHECK LIST

• Development: neurocranium, viscerocranium, cranial nerves, sensory organs, face, cranium with calvaria,
base of the skull, exit points with penetrating structures, temporomandibular joint and infratemporal fossa
• head and neck muscles, fascia and facial muscles, masticatory muscles, fascia of the head, hyoid bone and
suprahyal muscles • components of the head: nasal cavity (with orifices), paranasal sinuses, topographic
relationships, oral cavity, teeth, tongue, glands of the mouth, palate and function of the soft palate (cleft
formation), isthmusof fauces, WALDEYER's tonsillar ring, tonsils, pharynx, pterygopalatine fossa,
innervation and supply of all structures, facial paralysis and course of the cranial nerves [V, VII–XII]
Overview
Regions of head and neck

Fig. 8.1
Regions of the head and neck; frontal view.
The head is divided into the following topographic regions:
frontal region

temporal region

orbital region

nasal region

infraorbital region

zygomatic region

oral region

buccal region

mental region

parietal region

occipital region

parotideomasseteric region

The neck is divided into the following topographic regions:

anterior cervical region, composed of submental, submandibular, carotid, and muscular (omotracheal) triangle

sternocleidomastoid region with lesser supraclavicular fossa

lateral cervical region with omoclavicular triangle

posterior cervical region

Fig. 8.2
Regions of the head and neck; lateral view.

Skeleton and joints

Skull

Fig. 8.3
Skull, cranium; frontal view.
From bottom to top one can see the lower jaw or mandible, the two upper jaws or maxillary bones, the nasal bones located
between the maxillary bone and the orbit as well as the frontal bone above the orbit. The frontal bone consists of four
parts (→ Fig. 8.23 (f23) ). Above the supra-orbital margin the bilateral superciliary arch bulges out. A part of the frontal
bone protrudes medially downwards and forms a portion of the medial margin of the orbit. At the lateral aspect, the
zygomatic process has contact with the frontal process of the zygomatic bone. Both form the lateral margin of the orbit.
The zygomatic bone constitutes the major part of the lateral and lower margins of the orbit.
The pair of nasal bones is connected to the frontal bone by the frontonasal suture and to each other by the internasal
suture.

Fig. 8.4
LE FORT's fractures.

Car accidents are among the most frequent causes of midfacial fractures, which are classified
according to LE FORT (→ Fig. 8.4 (f5) ):

• LE FORT I: horizontal fracture line with isolated detachment of the maxillary alveolar rim
(“floating palate”)

• LE FORT II: pyramidal fracture line involving the maxillary bone in the region of the floor of the
orbit; involvement of the ethmoidal bones, anterior skull base, and nasal bones is also possible

• LE FORT III: transverse fracture line with craniofacial dissociation

Clinical Remarks

Skull bones
Fig. 8.5
Skull bones; frontal view; color chart see inside of the back cover of this volume.
The upper jaw or maxillary bone (maxilla) is located between the orbit and the oral cavity. The maxillary bone participates
in the formation of the lower and medial margins of the orbit and has a lateral border with the zygomatic bone. The frontal
process of the maxilla connects with the frontal bone. The infraorbital foramen is located below the lower margin of the
orbit in the body of the maxillary bone. The anterior nasal spine protrudes in the midline. The alveolar process creates the
lower margin of the maxilla and supports the teeth. In the orbit, the maxilla creates the lower margin of the inferior orbital
fissure and, together with the zygomatic bone, forms the lateral margin of the orbit.
The lower jaw or mandible consists of a body and the rami of mandible, which merge in the mandibular angle. The body of
mandible is composed of the alveolar parts with teeth and the base of mandible beneath. The latter protrudes in the
midline as mental protuberance. In addition, the mental foramen is shown.

Fractures of the nasal bone and the supporting cartilaginous nasal framework are among
the most frequent fractures of the facial region. One can distinguish closed and open nasal fractures.
Open fractures involve bony parts piercing through the skin and soft tissue. The nasal septum and
nasal conchae can also be affected. Fractures of the nasal framework are typically a result of violent
physical disputes, car accidents, martial arts like karate, boxing, and of a variety of team sports.

Clinical Remarks
Fig. 8.6
Skull bones; lateral view; color chart see inside of the back cover of this volume.
The lateral view displays parts of the frontal, parietal, occipital, sphenoidal, and temporal bones, parts of the
viscerocranium (nasal, lacrimal, maxillary, and zygomatic bones) as well as the lateral side of the lower jaw (mandible).
In the viscerocranium, the nasal bone has its cranial and posterior borders with the frontal bone and the maxilla,
respectively. The upper part of the lacrimal bone forms the fossa for lacrimal sac between maxilla and ethmoidal bone.
The alveolar process of the maxilla contains the upper teeth. The medial aspect of the maxilla connects with the frontal
bone, its lateral aspect contacts the zygomatic bone. The anterior nasal spine protrudes in the anterior midline. The
zygomatic bone is responsible for the contour of the region of the cheek.
The head of mandible articulates with the temporal bone in the temporomandibular joint.
In its upper frontal aspect, the frontal bone is connected with the parietal bone and the sphenoidal bone via the coronal
suture. The parietal bone connects with the occipital bone in the lambdoid suture and with the sphenoidal bone in the
shenoparietal suture. The sphenoidal bone and the temporal bone form the sphenosquamous suture. The temporal and
occipital bones connect in the posterior occipitomastoid suture. The major part of the lateral wall of the skull is formed by
the squamous part of the temporal bone.
The temporal bone and the zygomatic bone form the zygomatic arch, which bridges the temporal fossa. The tympanic part
of the temporal bone is located below the base of the zygomatic process and directly adjacent to the squamous part. At its
surface lies the external acoustic opening.
Fig. 8.7
Reference lines for the teeth.

Fig. 8.8
Skull bones; superior view; color chart see inside of the back cover of this volume.
A view on the upper part of the skull (skull cap, calvaria) reveals the frontal bone, the parietal bones, and the occipital
bone. The frontal bone and the parietal bones are separated by the coronal suture. Both parietal bones meet at the
sagittal suture. The occipital bone connects with the two parietal bones by the lambdoid suture. The contact point
between the coronal and sagittal sutures is called bregma, the contact point of the sagittal and lambdoid sutures is named
lambda. In the dorsal part of the parietal bones and bilaterally in close proximity to the sagittal suture are the paired
parietal foramina for the passage of the emissary veins.

Extensive external physical force can lead to skull fractures. Skull fractures are further
differentiated into:

• linear fractures presenting with clear fracture lines

• split skull fractures with multiple bony fragments (impression fracture with inward pointing bony
parts which can cause a compression or tear of the Dura mater as well as an injury to brain tissue)

• diastatic fractures (with fracture lines including sutures and result in a widening of the suture)

• basal skull fractures .

All fractures associated with an open wound of the skin of the head and fractures involving the
paranasal sinuses or the middle ear are considered to be open fractures with a risk of infection. They
require a surgical intervention.

Clinical Remarks

Fig. 8.9
Skull bones; posterior view; color chart see inside of the back cover of this volume.
This view from the posterior side shows the temporal, parietal, and the occipital bones. To both sides of the temporal bone
the mastoid process is visible. At the lower medial margin of the mastoid process lies the mastoid notch; this notch serves
as attachment point for the posterior belly of the digastric muscle.
Shown from posterior, both parietal bones meet in the midline in the sagittal suture, connect posteriorly with the occipital
bone in the lambdoid suture, and are separated laterally from the temporal bones by the parietomastoid suture.
The occipital bone occupies most of the posterior part of the skull. The central structure is the squamous part of occipital
bone. Frequently, sutural bones are found along the lambdoid suture. The external occipital protuberance is an easily
palpable bony reference point on the occipital bone. Its most protruding point is the inion. The protuberance extends
bilaterally in an arch-shaped line as superior nuchal line, a bony crest which serves for the attachment of the
autochthonous (intrinsic) muscles of the back. At approximately 2–2.5 cm below the external occipital protuberance, the
inferior nuchal line runs in a similar arch-shaped fashion, serving as additional attachment sites for muscles.

Fig. 8.10
Skull bones, right side; medial view; color chart see inside of the back cover of this volume.
The cranial cavity includes the skull cap (calvaria) and the base of the skull which is composed of the anterior, middle, and
posterior cranial fossae. The cranial cavity surrounds the brain with its meninges and encloses the proximal portion of the
cranial nerves, including the blood vessels and the venous sinuses. On the inside of the cranial cavity, the pulsations of the
medial meningeal artery have carved out grooves for arteries. The perpendicular plate of the ethmoidal bone and the
vomer, the bony part of the nasal septum, are located at the transition region from neurocranium to viscerocranium. The
palatine processes of the maxillary and palatine bone form the hard palate.
Fig. 8.11
Roof of the skull, calvaria; inner aspect; color chart see inside of the back cover of this volume.
The inside of the skull cap reveals the coronal suture between frontal bone and parietal bones and the lambdoid suture
between parietal bones and occipital bone. Also visible at the inside of the frontal bone is the frontal crest which serves as
an attachment for the falx cerebri (duplication of the dura mater composed of tough fibrous tissue; separates both cerebral
hemispheres). The frontal crest transitions into the groove of the superior sagittal sinus (location of the superior sagittal
sinus) which becomes wider and deeper in its posterior part. It extends across the lambdoid suture onto the occipital bone.
Bilaterally and alongside the entire length of the groove of the superior sagittal sinus, irregularly grouped small depressions
(granular foveolae, location of the cauliflower-like arachnoid granulations [PACCHIONIAN granulations]) are identified. The
lateral part of the calvaria contains multiple arterial and venous grooves.
The bones of the calvaria possess a special structure. They consist of a thick outer and thin inner compact layer, named
external and internal table, and a thin layer of spongiosa, known as diploë.

The internal table of the calvarian bones is thin and can be easily damaged by external forces that
result in a bending fracture of the table. If thereby branches of the medial meningeal artery (which
course in the groove for medial meningeal artery of the internal table) are injured, an epidural
hematoma may occur (→ Fig. 12.11 ).

Clinical Remarks

Inner aspect of the base of the skull

Fig. 8.12
Inner aspect of the base of the skull; superior view; color chart see inside of the back cover of this volume.
The anterior, middle, and posterior cranial fossae form the inner base of the skull. The frontal, ethmoidal, and sphenoidal
bones participate in the structure of the anterior cranial fossa. The latter is located above the nasal cavity and orbit and
contains the foramen cecum, the crista galli (attachment point for the falx cerebri), and the bilateral cribriform plate.
Posterior to the frontal bone and ethmoidal bones, the body and the lesser wings of the sphenoidal bone form the base of
the anterior cranial fossa. The body also forms the border to the middle cranial fossa.
The middle cranial fossa is composed of the sphenoidal and temporal bones. Its floor is elevated in the midline, and at
this point it becomes part of the body of the sphenoidal bone. The pit-shaped lateral portions are parts of the greater wing
of the sphenoidal bone and the squamous part of the temporal bone. Located in the middle cranial fossa are the saddle-
shaped sella turcica with the hypophysial fossa and, on both sides the optic canal, the superior orbital fissure, and the
foramina rotundum, ovale, spinosum, and lacerum. The anterior surface of petrous part demarcates the posterior aspect of
the middle cranial fossa.
Fig. 8.13
Inner aspect of the base of the skull; superior view.
Of the three cranial fossae, the posterior cranial fossa is the biggest. It is composed of the temporal bones, the occipital
bone, and, to a smaller extent, of the sphenoidal bone and the parietal bones.
In the midline, its anterior margin is formed by the dorsum sellae and the clivus. The clivus is an oblique bony rim, which
creates a slope from the dorsum sellae to the foramen magnum. The clivus is composed of parts of the body of the
sphenoidal bone and the basilar part of the occipital bone. The posterior aspect of the posterior cranial fossa consists
mainly of the groove for transverse sinus. The foramen magnum is the largest opening of the posterior cranial fossa.
Additional structures of the posterior cranial fossa include the hypoglossal canal, the internal acoustic pore, and the jugular
foramen. The groove for sigmoid sinus approaches the jugular foramen from lateral. The central depression in the posterior
cranial fossa is the cerebellar fossa.

Outer aspect of the base of the skull

Fig. 8.14
Outer aspect of the base of the skull; inferior view.
The cranial base extends to the middle incisors in the front, bilaterally to the mastoid process and the zygomatic arch, and
to the superior nuchal lines in the back. The cranial base divides into three compartments:
• anterior compartment with upper teeth and hard palate

• middle compartment posterior to the palate up to the anterior margin of the foramen magnum

• posterior compartment from the anterior margin of the foramen magnum to the superior nuchal lines

Anterior cranial base: encompasses the palate (→ Fig. 8.26 (f26) ).

Middle cranial base: the anterior part of this middle compartment is composed of the vomer and the sphenoidal bone; the
temporal bones and the occipital bone form the posterior part. The vomer is located in the frontal part of the midline, rides
on the sphenoidal bone, and constitutes the posterior part of the nasal septum.
The sphenoidal bone is composed of a central body and the paired greater and lesser wings (not visible from below).
Following directly the body of the sphenoidal bone is the basilar part of the occipital bone, which represents the beginning
of the posterior cranial base. The basilar part extends up to the foramen magnum. Here, the pharyngeal tubercle
protrudes. It constitutes the bony attachment point for parts of the pharynx.
(continuation → Fig. 8.15 (f16) )
Fig. 8.15
Outer aspect of the base of the skull; inferior view.
Middle cranial base (continuation of → Fig. 8.14 (f15) ): The sulcus of auditory tube is positioned at the border between
the greater wing of the sphenoidal bone and the petrous part of the temporal bone and forms the entrance into the bony
part of the auditory tube (→ p. 145 ). The bony canal continues through the petrous part of the temporal bone to the
tympanic cavity. Located laterally is the squamous part of the temporal bone which is involved in the formation of the
temporomandibular joint. The mandibular fossa is part of the articular surface of the temporomandibular joint (→ pp. 36–39
). The articular tubercle is located at the anterior margin of the mandibular fossa.
Posterior cranial base: The posterior compartment extends from the anterior margin of the foramen magnum to the
superior nuchal lines and consists of parts of the occipital and temporal bones. Each of the paired lateral parts possesses
an occipital condyle for the articulation with the atlas. Located behind the condyle is the condylar fossa, which contains the
condylar canal; anterior to the condyle the hypoglossal canal is situated. Immediately lateral thereof lies the jugular
foramen.

Foramina of the outer base of the skull

Fig. 8.16
Outer aspect of the base of the skull with foramina; inferior view; color chart see inside of the back cover of this
volume.

In basilar skull fractures the fracture lines traverse the openings at the base of the skull. Thus,
blood vessels and nerves passing through these openings can be injured with resulting nerve palsies
and bleedings as frequent complications. In addition, basilar skull fractures can involve the frontal,
sphenoidal, and ethmoidal sinuses (cerebrospinal fluid [CSF] and/or blood exiting through the nose).
Lateral basilar skull fractures often involve the petrous bone (CSF exiting from the outer ear canal).

Clinical Remarks

Foramina of the Outer Base of the Skull and their Content

Foramina Content

Incisive foramen • Nasopalatine nerve (maxillary nerve [V/2])

Foramina Content

Greater palatine foramen • Greater palatine nerve (maxillary nerve [V/2])

• Greater palatine artery (descending palatine artery)

Lesser palatine foramen • Lesser palatine nerves (maxillary nerve [V/2])

• Lesser palatine arteries (descending palatine artery)

Inferior orbital fissure • Infraorbital artery (maxillary artery)

• Inferior ophthalmic vein

• Infraorbital nerve (maxillary nerve [V/2])

• Zygomatic nerve (maxillary nerve [V/2])

Foramen rotundum (→ p. 12 ) • Maxillary nerve [V/2]

Foramen ovale • Mandibular nerve [V/3]

• Venous plexus of foramen ovale

Foramen spinosum • Meningeal branch (mandibular nerve [V/3])

• Medial meningeal artery (maxillary artery)

Sphenopetrosal fissure and foramen • Lesser petrosal nerve (glossopharyngeal nerve [IX]))
lacerum
• Greater petrosal nerve (facial nerve [VII]

• Deep petrosal nerve (internal carotid plexus)

External opening of carotid canal and • Internal carotid artery, petrous part
carotid canal
• Internal carotid venous plexus

• Internal carotid plexus (sympathetic trunk, superior

cervical ganglion)

Stylomastoid foramen • Facial nerve [VII]

Jugular foramen Anterior part:

• Inferior petrosal sinus

• Glossopharyngeal nerve [IX]

Posterior part:
• Posterior meningeal artery (ascending pharyngeal artery)

• Sigmoid sinus (superior bulb of jugular vein)

• Vagus nerve [X]

• Meningeal nerve (vagus nerve [X])

• Accessory nerve [XI]

Foramina Content

Mastoid canaliculus • Auricular branch of vagus nerve (vagus nerve [X])

Hypoglossal canal • Hypoglossal nerve [XII]

• Venous plexus of hypoglossal canal

Condylar canal • Condylar emissary vein

Foramen magnum • Meninges

• Internal vertebral venous plexus (marginal sinus)

• Vertebral arteries (subclavian arteries)

• Anterior spinal artery (vertebral arteries)

• Medulla oblongata/spinal cord

• Spinal roots (accessory nerve [XI])

Foramina of the inner base of the skull

Foramina of the Inner Aspect of the Base of the Skull and their Content

Foramina Content

Cribriform plate • Olfactory nerves [I]

• Anterior ethmoidal artery (ophthalmic artery)

Optic canal • Optic nerve [II]

• Ophthalmic artery (internal carotid artery)

• Meninges; sheath of optic nerve

Superior orbital fissure Middle part:

• Nasociliary nerve (ophthalmic nerve [V/1])

• Oculomotor nerve [III]

• Abducent nerve [VI]

Lateral part:
• Trochlear nerve [IV] mutual origin of:

– frontal nerve (ophthalmic nerve [V/1])

– lacrimal nerve (ophthalmic nerve [V/1])

• Orbital branch (medial meningeal artery)

• Superior ophthalmic artery

Foramen rotundum • Maxillary nerve [V/2]

Foramina Content

Foramen ovale • Mandibular nerve [V/3]

• Venous plexus of foramen ovale

Foramen spinosum • Meningeal branch (mandibular nerve [V/3])

• Medial meningeal artery (maxillary artery)

Sphenopetrosal fissure and foramen • Lesser petrosal nerve (glossopharyngeal nerve [IX])
lacerum
• Greater petrosal nerve (facial nerve [VII])

• Deep petrosal nerve (internal carotid plexus)

Internal opening of carotid canal and • Internal carotid artery, petrous part
carotid canal
• Internal carotid venous plexus

• Internal carotid plexus (sympathetic trunk, superior

cervical ganglion)

Pore and internal acoustic meatus • Facial nerve [VII]

• Vestibulocochlear nerve [VIII]

• Labyrinthine artery (basilar artery)

• Labyrinthine veins

Jugular foramen Anterior part:

• Inferior petrosal sinus

• Glossopharyngeal nerve [IX]

Posterior part:
• Posterior meningeal artery (ascending pharyngeal artery)

• Sigmoid sinus (superior bulb of jugular vein)

• Vagus nerve [X]

• Accessory nerve [XI]

• Meningeal branch (vagus nerve [X])

Hypoglossal canal • Hypoglossal nerve [XII]

• Venous plexus of hypoglossal canal

Condylary canal • Condylar emissary vein

Foramina Content

Foramen magnum • Meninges

• Internal vertebral venous plexus (marginal sinus)

• Vertebral arteries (subclavian arteries)

• Anterior spinal artery (vertebral arteries)

• Medulla oblongata/spinal cord

• Spinal roots (accessory nerve [XI])

Fig. 8.17
Inner aspect of the base of the skull with foramina; superior view; color chart see inside of the back cover of this
volume.

Development of the skull

Fig. 8.18 and Fig. 8.19
Skull of a newborn; frontal (→ Fig. 8.18 (f19) ) and lateral (→ Fig. 8.19 (f19) ) views; color chart see inside of the back
cover of this volume.
At birth, the newborn has six fontanelles, two unpaired (anterior and posterior fontanelle) and two paired (sphenoidal and
mastoid fontanelles). During delivery, sutures and fontanelles serve as reference structures to assess the location and
position of the fetal head. Shortly before birth, the posterior fontanelle becomes the leading part of the head in the case of
a normal cephalic presentation.
In concert with the sutures, the fontanelles allow a limited deformation of the fetal skull during delivery. The remarkable
postnatal growth results in the fontanelles becoming rapidly smaller and complete closure will occur by the end of the third
year of life.
Fig. 8.20
Skull of a newborn; superior view; color chart see inside of the back cover of this volume.
At birth, the bony plates of the skull cap (calvaria) are still separated by the interstitial tissue located in the cranial sutures.
The sutures are widened to fontanelles in regions where more than two bones meet. During life, most sutures, fontanelles,
and synchondroses ossify. Important sutures include the lambdoid suture, frontal suture, sagittal suture, and coronal
suture which gradually fuse up to about 50 years of age (the frontal suture already between the first and second year of
life).

Fontanelles

Fontanelle Number Closure [month of life]

Anterior fontanelle (large fontanelle) 1 Approx. 36

Posterior fontanelle (small fontanelle) 1 Approx. 3

Sphenoidal fontanelle (anterior lateral fontanelle) Paired Approx. 6

Mastoid fontanelle (posterior lateral fontanelle) Paired Approx. 18

Fig. 8.21
Skull, cranium, of a newborn; posterior inferior view; color chart see inside of the back cover of this volume.
The development of the skull involves a desmal and an enchondral ossification mode (→ table). The mesenchyme of the
head is the primordial building material that derives from the prechordal mesoderm, the occipital somites, and the neural
crest. At the time of birth, some cranial bones are linked by cartilaginous joints (cranial synchondroses).

Ossification Mode of the Skull Bones

Viscerocranium Neurocranium Ossicles

Desmal Mandibular bone except for Medial plate of the pterygoid process of the
condylar process, maxilla, sphenoidal bone, squamous part of the
zygomatic bone, palatine bone, temporal bone, squamous part of occipital
nasal bone, vomer, lacrimal bone, frontal bone, parietal bone
bone

Chondral Condylar process of the Sphenoidal bone except for medial plate of
mandibular bone, ethmoidal the pterygoid process, petrous part and
bone, inferior nasal concha tympanic part of the temporal bone, lateral
part and basilar part of the occipital bone

MECKEL's Malleus,
cartilage incus

REICHERT's Styloid process of the temporal bone Stapes

cartilage

Craniostenoses

Figs. 8.22a and b

Craniostenoses; child with scaphocephalus. [20] This clinical picture is the result of a premature closure of the sagittal
suture. The skull cap is disproportionally long.
a superior view

b view from the right side

 A dysostosis is a deviation from normal bony growth. The premature closure of one or more sutures
results in craniosynostoses. Premature closure of the sagittal suture results in the extension of the
skull in the frontal and occipital region. The skull becomes longer and narrower (scaphocephaly).
The premature closure of the coronal sutures results in acrocephaly (also named turricephaly).
Asymmetric craniosynostosis (plagiocephaly) results from unilateral premature occlusion of the
coronal and lambdoid sutures. Microcephaly results from impaired growth of the brain because the
growth of the skull bones adjusts to the size of the brain. Thus, small brain size causes an
underdeveloped neurocranium and mental retardation in children with microcephaly.

Clinical Remarks

Frontal and ethmoidal bones

Fig. 8.23
Frontal bone; frontal view; color chart see inside of the back cover of this volume.
Located most anterior in the skull cap, the frontal bone participates in the formation of the walls of the orbital and nasal
cavity. The unpaired frontal bone has four parts :
• the unpaired squamous part

• the paired orbital parts and

• the unpaired nasal part

Above the upper margin of the orbit (supra-orbital margin) the prominent superciliary arch protrudes, a phenotype
commonly more developed in men than in women. In the midline between the two arches, the bone is flat and creates the
glabella (area between the eyebrows). Frequently, a supraorbital foramen, more rarely a frontal notch, is present at the
medial margin of the orbit.
Fig. 8.24
Frontal bone, ethmoidal bone, and nasal bones; inferior view; color chart see inside of the back cover of this volume.
The ethmoidal bone and nasal bones connect with the frontal bone in a medial anterior and caudal position and form part
of the nasal skeleton. The frontal sinus is located within the frontal bone.

Upper jaw and palatine bone

Fig. 8.25
Upper jaw, maxilla, right side; lateral view.
The upper jaw can be divided into the body of maxilla, frontal process (connects with the frontal bone), zygomatic process
(connects with the zygomatic bone), palatine process (anterior part of the palate, → Fig. 8.26 (f26) ), and alveolar process.
The latter creates the lower margin of the maxilla and is composed of the dental alveoli which contain the roots of the
teeth. The protruding anterior rim of these dental sockets are named alveolar yokes. The infraorbital foramen is located in
the body of maxilla, immediately below the lower orbital margin.
Fig. 8.26
Upper jaw, maxilla, and palatine bone, right side; medial view into the maxillary sinus; color chart see inside of the back
cover of this volume.
Posterior to the maxilla lies the palatine bone which is composed of two plates: The horizontal plate creates the posterior
part of the palate (bony palate), the perpendicular plate extends vertically upright (perpendicular to the horizontal plate)
and is the posterior medial margin of the maxillary sinus.

Nasal cavity

Fig. 8.27
Bony septum of the nose ; lateral view; color chart see inside of the back cover of this volume.
The perpendicular plate of the ethmoidal bone and the vomer create the bony septum of the nose. The ethmoidal bone is
located between the frontal bone and the maxilla and is also connected with the nasal, lacrimal, sphenoidal, and palatine
bones. At its top, the ethmoidal bone forms the crista galli. Perforated with multiple holes, the cribriform plate is the roof of
the nasal cavity and part of the floor of the anterior cranial fossa. The perpendicular plate of the ethmoidal bone is located
below the crista galli, divides the bony labyrinth of the ethmoidal bone into a right and left part, and constitutes the upper
part of the bony nasal septum.
The vomer forms the largest part of the bony nasal septal skeleton. This flat and trapezoid bone connects cranially with
the perpendicular plate of the ethmoidal bone and at its posterior aspect via the ala of vomer with the sphenoidal bone.
Caudally, the cuneiform part of vomer borders at the palatine process of the maxilla and at the horizontal plate of the
palatine bone.

Traumatic events (punched nose or falls onto the nose) or abnormal growth of the maxilla can cause a
septum deviation. More than 60% of the population has at least a mild septum deviation. Septum
deviations mainly impair breathing through the nose. This can affect the ability of the nose to warm
up, clean, and moisturize the air passing through the nose. In turn, patients with impaired nasal
breathing are forced to breathe through their mouth, which results in snoring and an increased
susceptibility for infections. Insufficient ventilation of the paranasal sinuses may cause sinusitis with
postnasal drip and potential inflammation of the larynx and the bronchial tree. At an advanced age,
this can lead to hypoxia and subsequently results in cardiovascular diseases.

Clinical Remarks

Fig. 8.28
Lateral wall of the nasal cavity, right side; view from the left side; color chart see inside of the back cover of this volume.
The view onto the lateral wall of the nasal cavity reveals the roof created by the cribriform plate of the ethmoidal bone
which also forms the superior and middle nasal concha. The upper nasal passage (superior nasal meatus) is located
between the two nasal conchae. Below sits the inferior nasal concha as a separate bone.
Fig. 8.29
Lateral wall of the nasal cavity, right side; medial view after the middle nasal concha was removed; color chart see
inside of the back cover of this volume.
Beneath the middle nasal concha, a thin bony lamella, the uncinate process, is part of the ethmoidal bone. It provides
only an incomplete closure of the medial wall of the maxillary sinus. Many openings remain above and below the uncinate
process and one of them is the maxillary hiatus.
The maxilla and the palatine bone create the floor and parts of the lateral wall (floor: horizontal plate; lateral wall:
perpendicular plate). The lacrimal bone is also part of the lateral wall and contributes to the anterior margin of the
maxillary sinus. The inferior nasal concha is anchored to all of these three bones and divides the nasal wall in a middle
(medial nasal meatus) and an inferior nasal passage (inferior nasal meatus) which are located above and below this nasal
concha, respectively.

Hard palate

Fig. 8.30
Hard palate; maxillary sinus, and inferior nasal concha; superior view; color chart see inside of the back cover of this
volume.
The hard palate represents a horizontal bony plate created by the maxilla and the palatine bone. It separates the oral front
from the nasal cavity. The incisive foramen creates a connection between both cavities. The present image shows the floor
of the nasal cavity. Located laterally are the maxillary sinuses.
Fig. 8.31
Hard palate; inferior view; color chart see inside of the back cover of this volume.
The hard palate is part of the anterior cranial fossa. The teeth are attached to the two maxillary alveolar arches. These
arches are the anterior and lateral margins of the hard palate. Its rostral part consists of the palatine processes of the two
maxillae and the horizontal plates of the palatine bones in its posterior aspect. In the midline, the palatine processes are
connected by the median palatine suture and dorsally they connect via the transverse palatine suture with the palatine
bones. The horizontal plates of the palatine bones are connected in the midline by the interpalatine suture (a continuation
of the median palatine suture).
Located behind the incisures in the frontal part of the midline are the paired incisive fossae which become the incisive
foramina and the incisive canals. Near the posterior margin to both sides of the hard palate are the greater palatine
foramina, which become the greater palatine canals, and the lesser palatine foramina. The latter are located in the
pyramidal process of the palatine bone and open into the lesser palatine canals. In the posterior aspect of the midline, the
posterior nasal spine protrudes as a pointed process of the hard palate.

Orbit and pterygopalatine fossa

Fig. 8.32
Floor of the orbital cavity, left side; superior view; color chart see inside of the back cover of this volume.
The floor of the orbit is the roof of the maxillary sinus. In it lies the infraorbital sulcus, which becomes a bony canal below
the floor of the orbit and ends in the infraorbital foramen. It contains the infraorbital nerve and the corresponding blood
vessels. The zygomatic bone forms the lateral part of the floor of the orbit and the medial part is composed of the orbital
plate of the ethmoidal and lacrimal bone. Together with the maxilla, the latter creates the fossa of lacrimal gland containing
the lacrimal gland. For the orbital cavity → Figs. 9.9 to 9.13 Fig.9.10 Fig.9.11 Fig.9.12 Fig.9.13 .
Fig. 8.33
Pterygopalatine fossa, left side; lateral view; color chart see inside of the back cover of this volume.
The pterygopalatine fossa is the medial continuation of the infratemporal fossa. Its bony margins are the maxilla, the
palatine bone, and the sphenoidal bone. This fossa is an important relais station connecting the middle cranial fossa, the
orbit, and the nasal cavity. It serves as a conduit for many nerves and blood vessels located in these structures (→ pp. 78
and 79 ).
The lateral access route to the pterygopalatine fossa is a common surgical strategy for the resection of tumors in this
region, such as nasopharyngeal fibroma.

Orbit

Fig. 8.34
Orbit, left side; frontal view; probe in the infraorbital canal; color chart see inside of the back cover of this volume.
The ethmoidal, lacrimal, palatine, sphenoidal, zygomatic, and maxillary bones create the margins of the orbital cavity.
Passages to and from the orbit are the superior and inferior orbital fissures, the optic canal, and the anterior and posterior
ethmoidal foramina. Located in the posterior part of the orbital floor, the infraorbital sulcus becomes the infraorbital canal
which projects towards the front of the orbit and ends as infraorbital foramen located below the inferior margin of the orbit.
Positioned laterally, the zygomatic bone regularly contains a zygomaticofacial foramen. For the orbital cavity → Figs. 9.9 to
9.13 Fig.9.10 Fig.9.11 Fig.9.12 Fig.9.13 .
Fig. 8.35
Viscerocranium; frontal section at the level of the two orbits; frontal view; color chart see inside of the back cover of this
volume.
The unpaired ethmoidal bone contains the anterior and posterior ethmoidal cells. The perpendicular plate of the
ethmoidal bone lies immediately beneath the crista galli, separates the bony labyrinth of the ethmoidal bone into a right
and a left half, and participates in the upper part of the bony nasal septum. At its posterior aspect it is followed by the
vomer. The lateral walls of the ethmoidal cells consist of a thin orbital lamina, known as lamina papyracea, constituting
the major part of the medial wall of the orbit. The maxillary sinus is located directly below the orbit. The infraorbital canal is
located in its roof, which also constitutes the floor of the orbit. The cribriform plate positions clearly below the roof of the
orbit. For the orbital cavity → Figs. 9.9 to 9.13 Fig.9.10 Fig.9.11 Fig.9.12 Fig.9.13 .

The paper-thin orbital lamina (lamina papyracea) of the ethmoidal bone between the orbit and the
ethmoidal sinuses represents no barrier to the spreading of an inflammation from the ethmoidal
cells into the orbit which can escalate into an orbital phlegmon. Figure 8.35 (f35) demonstrates the
close proximity between a roots of a molar tooth and the maxillary sinus. Inflammations of the second
premolars and/or the first molars can lead to an odontogenic inflammation of the maxillary sinus
(maxillary sinusitis).

Clinical Remarks
Fig. 8.36
Lateral wall of the orbit, right side; medial view; color chart see inside of the back cover of this volume.
The zygomatic, frontal, sphenoidal, and maxillary bones form the lateral wall of the orbit. The infraorbital canal is depicted
clearly in the anterior third of the orbital floor, as is the very thin bony layer separating the orbit from the maxillary sinus.
The pterygopalatine fossa is located posteriorly to the maxillary sinus and connects laterally to the infratemporal fossa,
cranially to the orbit, and in its inferior aspect connects to the oral cavity via the greater palatine canal. From a posterior
cranial position, the pterygoid canal exits into the pterygopalatine fossa.

Fig. 8.37
Medial wall of the orbit, left side; lateral view; color chart see inside of the back cover of this volume.
The lacrimal bone, the maxilla, and the frontal bone form the anterior part of the medial wall of the orbit, whereas in the
posterior part the orbital lamina of the ethmoidal bone (lamina papyracea), the orbital process of the palatine bone, and the
sphenoidal bone are placed between the frontal bone and the maxilla. Both, the anterior lacrimal crest of the maxilla and
the posterior lacrimal crest of the lacrimal bone provide the margins for a depression (fossa for lacrimal gland) of the
lacrimal sac. Located in the medial wall of the orbit are the anterior and posterior ethmoidal foramina and the optic canal.
The sphenopalatine foramen is located at the top of the pterygopalatine fossa.

Sphenoidal bone
Fig. 8.38
Sphenoidal bone; frontal view.
The unpaired sphenoidal bone connects the viscerocranium with the neurocranium. Two pairs of wing-shaped bones
extend from the body of the sphenoidal bone. The lesser wings sit on the top, the greater wings at the bottom, and below
the pterygoid processes project. The center of the sphenoidal bone contains the sphenoidal sinuses. The sphenoidal
crest subdivides the anterior part of the body into two halves.

Fig. 8.39
Sphenoidal bone; posterior view.
The lesser and greater wings of the sphenoidal bone participate in the formation of the superior orbital fissure. On both
sides, the pterygoid process divides into a smaller medial lamina and a larger lateral lamina, which create the pterygoid
notch and enclose the pterygoid fossa. The pterygoid hamulus is the caudal extension of the medial lamina. At its base,
the pterygoid canal perforates the sphenoidal bone and enters into the pterygopalatine fossa.

Sphenoidal bone and occipital bone

Fig. 8.40
Sphenoidal bone and occipital bone; superior view; color chart see inside of the back cover of this volume.
The center of the sphenoidal bone is composed of the sella turcica with the hypophysial fossa. The Tuberculum sellae
creates the anterior rim of the hypophysial fossa and extends laterally into the medial clinoid process. The prechiasmatic
sulcus and the jugum sphenoidale (sphenoidal yoke) are located in front of the Tuberculum sellae. The clivus forms the
posterior part of the saddle-shaped sella turcica and the posterior clinoid process represents the lateral elevated end of its
upper rim. In the region of the sella turcica and at its anterior rim, the optic canal perforates the lesser wing. The foramina
rotundum, ovale, and spinosum pierce the greater wing bilaterally in an anterior cranial to posterior caudal direction.
The unpaired occipital bone is composed of the squamous part, two lateral parts, and one basilar part. These four parts
delimit the foramen magnum. At the inner surface of the squamous part of occipital bone, the groove of the superior
sagittal sinus and the grooves for the transverse sinus meet at the internal occipital protuberance. Further, the grooves for
the sigmoid sinus and the occipital sinus are visible at the inner surface. Above and below the occipital protuberance, the
inner surface of the squamous part of the occipital bone forms the cerebral fossa and the cerebellar fossa, respectively.
Together with the body of the sphenoidal bone, the basilar part of the occipital bone generates the clivus.

Temporal bone
Fig. 8.41
Temporal bone, right side; lateral view.
The paired temporal bone is part of the viscerocranium and neurocranium. It participates in the formation of the lateral side
and the base of the cranium. The squamous part, the tympanic part, and the petrous part (petrous bone) can be
distinguished.
Through its parietal border, the squamous part connects with the parietal bone. The zygomatic process protrudes anterior
and superior of the meatus and extends in an anterior direction.
The petrous part borders at the parietal and occipital bones. The central outer opening is the external acoustic meatus.
Located at its posterior caudal aspect is the mastoid process. Middle and inner ear are located within the petrous part (not
visible). Access routes are the internal acoustic meatus, → p. 17 ), the stylomastoid foramen (→ p. 16 ) and the
musculotubal canal (→ Figs. 10.30 and 10.37 ).
The tympanic part forms the bony wall of the external acoustic meatus. As a ring-shaped structure, it is associated with
the squamous and petrous parts. The tympanic part delimits the external acoustic meatus at its frontal, caudal, and
posterior side and extends to the tympanic membrane (→ Figs. 10.15 and 10.25 ).

Fig. 8.42
Temporal bone, of a newborn, right side; lateral view; schematic drawing; color chart see inside of the back cover of this
volume.
The image displays different parts of the temporal bone: squamous part, petrous part, and tympanic part.

Temporal bone
Fig. 8.43
Temporal bone, right side; inner aspect.
The petrous part is shaped like a pyramid with its tip (apex of petrous part) directed anterior medial and its base pointing
towards the mastoid process. The anterior surface is part of the middle cranial fossa and contains the protruding arcuate
eminence; contained within the posterior surface is the internal acoustic pore which constitutes the entrance to the
internal acoustic meatus. The posterior surface of the petrous part shows the indentation by the groove of the sigmoid
sinus. The mastoid foramen is located here as well. On the inner surface (cerebral surface) of the squamous part the
grooves for arteries of the medial meningeal artery are visible.

Fig. 8.44
Temporal bone, right side; inferior view.
The inferior surface of the temporal bone depresses to become the jugular fossa and, together with the occipital bone,
delineates the jugular foramen. The notch at the border between the squamous and petrous part indicates the starting
point of the musculotubal canal. In addition, the external opening of the carotid canal and the styloid process are visible.
The stylomastoid foramen opens to the lateral posterior side. Just in front of the external acoustic meatus, the squamous
part contains the mandibular fossa which, at its rostral aspect, is demarcated by the articular tubercle.

Lower jaw
Fig. 8.45
Lower jaw, mandible; frontal view.
The unpaired mandible consists of a body of the mandible and two rami. Each ramus divides into a coronoid process and
a condylar process. The body of the mandible is composed of the base and the alveolar part separated by the oblique
line which descends from the coronoid process in an oblique anterior trajectory. The frontal part of the alveolar part
consists of the chin (mentum) with the mental protuberance, the bilateral mental tubercles and the mental foramina.

Fig. 8.46
Lower jaw, mandible; lateral view. Body and ramus of mandible merge at the angle of mandible.
The head of mandible sits on top of the condylary process.

Fig. 8.47
Lower jaw, mandible; inner aspect of the mandibular arch.
The mandibular foramen is located at the inside of the ramus of mandible. In front thereof, the mylohyoid line creates a
stepwise crest, which serves as an attachment for the mylohyoid muscle and demarcates the level of the floor of the
mouth.
Lower jaw

Fig. 8.48
Lower jaw, mandible; inferior view.
The mental spine is located at the inside of the mandible close to the midline. Bony depressions represent the digastric
fossa below and lateral to the mental spine and the sublingual fossa and submandibular fossa above the mental spine. On
the inside of the angle of mandible the pterygoid tuberosity is found.

Fig. 8.49
Lower jaw, mandible, of an old person.
Loss of teeth – particularly at an advanced age – results in a regression of the alveolar part of the mandible. This can
progress until the mental foramen becomes located at the upper rim of the toothless lower jaw. The angle of mandible
has a much wider angle than in a mandible with dentition.

Fig. 8.50
Lower jaw, mandible, of a newborn.
In a newborn, the mandibular symphysis connects the two mandibular segments. The angle between the body and
ramus of mandible is still very large.
 Apart from nasal fractures, fractures of the mandible are common due to its exposed location in the
head region. The U-shaped structure explains the various types of mandibular fractures, in particular
at the level of the canines and the third molar teeth. Extravasated blood from the mandible collects in
the loose tissue of the floor of the mouth, results in small spotted bleeding under the skin
(ekchymoses), and is a typical sign of a mandibular fracture. Without proper prosthetic
reconstruction, a loss of teeth results in the regression of the alveolar part of mandible in the area of
the lost teeth. The fitting of a dental prosthesis onto a largely regressed alveolar part is exceedingly
difficult and often requires bone reconstruction.

Clinical Remarks

Temporomandibular joint

Fig. 8.51
Temporomandibular joint, right side; lateral view.
A wide cone-shaped joint capsule stretching from the temporal bone to the condylar process surrounds the mandibular
joint. In its frontal and lateral parts, the lateral ligament reinforces the joint capsule and extends from the zygomatic arch in
an oblique posterior caudal direction to the head of mandible. At the inside of the joint (not shown), connective tissue
generates the variable medial ligament. The lateral and medial ligaments (if present) assist in guiding the joint movements
and foremost inhibit posterior movements of the mandibular head. When bite force is applied, the lateral ligament also
stabilizes the condyle. The stylomandibular ligament projects from the styloid process to the posterior rim of the ramus of
mandible. It is usually weak and, together with the sphenomandibular ligament, resists further lower jaw movements at a
position close to maximal opening of the mouth (→ Fig. 8.52 (f52) ).
Fig. 8.52
Stylomandibular ligament and sphenomandibular ligament, right side; medial view.
Both ligaments affect the kinematics of the temporomandibular joint but are not associated with the joint capsule.
The strong sphenomandibular ligament has its origin at the spine of sphenoidal bone and passes between the lateral
and medial pterygoid and inserts in a fan-shaped pattern at the lingula of mandible. The stylomandibular ligament
originates from the styloid process and projects to the angle of mandible. Together, both ligaments inhibit lower jaw
movements at a position close to the maximal opening of the mouth.
The pterygospinous ligament has no relationship to the temporomandibular joint nor does it affect the joint kinematics. It
has its origin at the spine of sphenoidal bone and inserts at the lateral lamina of the pterygoid process. This ligament has a
stabilizing function.

Fig. 8.53
Temporomandibular joint, left side; sagittal section; lateral view; mouth almost closed.
In the temporomandibular joint, the head of mandible, mandibular fossa, and articular tubercle of the temporal bone
articulate with each other. Both joint components are separated by an articular disc. The temporomandibular joint is
positioned in front of the bony part of the external acoustic pore.
Fig. 8.54
Temporomandibular joint, left side; sagittal section; lateral view; mouth opened. [8]
An articular disc completely divides the temporomandibular joint into two separate chambers (dithalamic joint):
• The lower chamber permits hinge-like opening and closure movements of the mandible.

• The upper chamber allows for the head of mandible to slide forward on the articular tubercle (protrusion). This
particularly requires the action of the lateral pterygoid. The movement back into the mandibular fossa is called retraction
(retrusion).

Fig. 8.55
Movements of the temporomandibular joint, left side; lateral view. [8]
Independent movements in one temporomandibular joint are not possible because both temporomandibular joints are
joined in the bony mandibular arch. The temporomandibular joints permit two main functions during chewing: elevation
(adduction) and depression (abduction) of the lower jaw as well as grinding movements. Apart from abduction and
adduction, the forward (protrusion) and backward movement (retrusion) as well as grinding (sideways sliding –
laterotrusion and mediotrusion ) constitute the movement patterns of the temporomandibular joint. The masticatory
muscles contribute in different ways to the mobility of the joint.
Fig. 8.56
Fossa and tubercle of the temporomandibular joint, right side; inferior view.
View onto the articular surface of the mandibular fossa, which is normally covered with hyaline articular cartilage. Also
covered by hyaline cartilage, the articular tubercle is located anterior to the mandibular fossa. In the posterior third of the
mandibular fossa, the squamous part connects with the petrous part of the temporal bone, and medially the temporal bone
borders at the sphenoidal bone. As a result, this region contains three fissures:
• In a lateral position the tympanosquamous fissure is visible.

• In the middle lies the petrotympanic fissure (* GLASERIAN fissure).

• Medially runs the sphenopetrous fissure through which the chorda tympani leaves the cranial basis.

Fig. 8.57
Articular process, condylary process, of the lower jaw, right side; frontal view.
The condylary process is composed of the head and neck of mandible. At the frontal side, it contains the pterygoid fovea.
Here, the lateral pterygoid attaches with its inferior head.

Figs. 8.58a and b

Articular disc of the temporomandibular joint.
a Superior view

b Lateral view

From front to back, the articular disc consists of an anterior ligament (connective tissue), an intermediate zone (fibrous
cartilage), a posterior ligament (connective tissue), and a bilaminar zone (connective tissue). In its lateral part, the
intermediate zone is particularly thin.
Fig. 8.59
Temporomandibular joint; sagittal section at the level of the temporomandibular joint region with injected veins (colored);
lateral view. [1]
The bilaminar zone between the articular tubercle and head of mandible is visible. The bony septum between the middle
cranial fossa and the mandibular fossa is thin. Among the connective tissue of the bilaminar zone lies an extensive retro-
articular venous plexus. Close proximity exists to the external acoustic meatus.

Significant external force can result in the fracture of the neck of mandible (condylar fracture). An
involvement of the joint capsule and the occurence of dislocated bone fragments is possible in such
fractures. In addition, bleeding from the retro-articular venous plexus (→ Fig. 8.59 (f59) ) and/or
painful sensations from the external acoustic meatus may occur. The temporomandibular joint is a
diathrosis. Thus, this joint can be afflected by the same diseases that also affect the large joints of the
limbs, e.g. arthrosis or rheumatoid arthritis. In case of an arthrosis of the temporomandibular
joint, the lateral part of the articular disc is mostly affected.

Clinical Remarks

Temporomandibular joint, radiography

Fig. 8.60
Temporomandibular joint; computed tomographic image in lateral beam projection; mouth closed.
With the mouth closed and masticatory muscles relaxed, the condylar process resides in the mandibular fossa.
Fig. 8.61
Temporomandibular joint; computed tomographic image in lateral beam projection; mouth open.
With the mouth open, the articular disc and the condylar process move forward onto the articular tubercle.

Muscles
Facial muscles
Fig. 8.62
Facial muscles and masticatory muscles; frontal view.
Mimic muscles determine the facial expression and create the individual appearance of a facial physiognomy of a person.
The muscles around the eye have important protective functions, while the muscles in the region of the mouth serve in
food uptake and articulation.
Visible on both sides of the face are the frontal belly of the occipitofrontalis (epicranius), the orbital and palpebral parts of
the orbicularis oculi (lacrimal part → Fig. 9.19 ), the corrugator supercilii, procerus, nasalis, depressor septi nasi, levator
labii superioris alaeque nasi, the orbicularis oris with a labial and marginal part, the buccinator, zygomatici major and minor,
risorius, levator labii superioris, levator anguli oris, depressor anguli oris, depressor labii inferioris and mentalis as well as
the platysma projecting onto the neck.
Of the masticatory muscles, only the masseter on the left side of the face is shown. The parotid duct (STENSON's duct) of
the parotid gland passes across the masseter and bends around its frontal edge in an almost right angle to penetrate the
buccinator. A buccal fat pad (BICHAT's fat pad) is located between the masseter and buccinator and contributes to the
contour of the region of the cheek. With the exception of the buccinator, the facial muscles do not contain a fascia. The
fasciae of the buccinator, the masseter, and the parotid gland have been removed.
Fig. 8.63
Facial muscles, left side; lateral view.
In addition to the muscles displayed in → Figure 8.62 (f62) , this lateral view also shows the occipital belly of the
occipitofrontalis (epicranius) with the epicranial aponeurosis extending between the frontal and occipital belly. Located
above the ear and also projecting into the epicranial aponeurosis is the temporoparietalis (also a part of the epicranius)
which originates from the temporal fascia. Additional mimetic muscles are also shown and include the auriculares anterior,
superior, and posterior. In the neck region, parts of the sternocleidomastoid, the trapezius, and some autochthonous
muscles of the back are visible.

Paralysis of the orbicularis oculi as part of a paresis of the facial nerve [VII] (facial palsy) results
in the inability to voluntarily close the eyelid, causing it to stay open even during sleep (paralytic
lagophthalmos, → Fig. 12.151 ). Due to lack of tension, the lower eyelid becomes flaccid and hangs
down (paralytic ectropion). The inferior canaliculus fails to drain the lacrimal fluid from the eye.
Instead, the fluid passes over the everted lower eyelid onto the cheek (drooping eye, epiphora ). The
inability to blink the eye causes the cornea to dry out and results in corneal lesions (keratitis) and an
opaque cornea.

The decrease in tension in the lower eyelid at an advanced age can lead to the so-called senile
ectropion.

Paralysis of the orbicularis oris (also in the context of a facial palsy) results in speech disabilities.
The corner of the mouth on the paralysed side hangs down and saliva involuntarily droops from the
mouth.

Clinical Remarks

Facial and masticatory muscles

Fig. 8.64
Facial muscles and masticatory muscles; lateral view from an oblique angle.
The fascia of the buccinator, the masseter, the parotid gland as well as part of the superficial fascia of the neck were
removed. As a result, the corresponding muscles, the parotid gland extending to the neck, and the submandibular gland
become visible. The major excretory duct of the parotid gland, the parotid duct (STENSEN's duct), exits the gland at its
anterior pole, crosses the masseter in a horizontal line from posterior to anterior and, at the anterior margin of the
masseter, bends inwards in an almost perfect right angle to penetrate the buccinator. Between the buccinator and
masseter lies the buccal fat pad (BICHAT's fat pad). Associated with the parotid duct is accessory glandular tissue
(accessory parotid gland).
In the temporal region, the parietoparietalis of the epicranius was removed. This allows a clear view onto the superficial
lamina of the temporal fascia.
Above the zygomatic arch parts of the superficial lamina and the temporal fat pad underneath were removed to permit a
clear view onto the deep lamina of the temporal fascia with the temporalis shining through.

Swelling of the parotid gland (e.g. in the case of an epidemic parotitis [mumps], → p. 90 ) can
cause severe pain sensations because of the close proximity of the parotid gland to the masticatory
muscles and the fact that the parotid gland and the masseter share a mutual fascia
(parotideomasseteric fascia). Often, the pain also involves the external acoustic meatus and is
aggravated by palpating the tragus or the auricle (tragus pain).

Patients with a malignant tumor disease (tumor cachexia) or suffering from advanced stages of
HIV infection are often emaciated. The BICHAT's fat pad which models the typical contour of the
cheeks is wasting and gives way to the emaciated cheeks in these patients.
 Clinical Remarks

Fig. 8.65
Facial muscles and masticatory muscles, left side; lateral view.
Upon removal of the superficial and the deep laminae of the temporal fascia and the partial removal of the zygomatic arch
and parts of the masseter, the temporalis becomes visible.
The origin of the temporalis along the inferior temporal line of the external surface of the parietal bone and the temporal
line of the frontal bone are shown. The muscle fibers converge into a flat tendon that disappears in the infratemporal fossa
behind the zygomatic arch and inserts at the coronoid process.
Origins of the temporalis:
• inferior temporal line of the external surface of the parietal bone

• temporal surface of the frontal bone

• temporal surface, squamous part of the temporal bone

• temporal surface of the zygomatic bone

• temporal surface of the sphenoidal bone up to the infratemporal crest

The image also displays a few suprahyal muscles (digastric with anterior belly and posterior belly, stylohyoid).

Masticatory muscles
Fig. 8.66
Masseter and temporalis, left side; lateral view.
The masseter consists of a superficial part and a deep part.

Fig. 8.67
Temporomandibular joint, medial pterygoid, and lateral pterygoid, left side; lateral view.
The medial pterygoid consists of a medial part and a lateral part.
Fig. 8.68
Temporomandibular joint and relationship to the lateral pterygoid, left side; lateral view.
The lateral pterygoid consists of an upper head and a lower head (→ Fig. 8.67 (f67) ).

Fig. 8.69
Masticatory muscles; frontal section at the level of the temporomandibular joint and horizontal section of the skull cap;
posterior view.
The bilateral insertion sites of the masseter and medial pterygoid at the angle of mandible are shown. The mandible is
suspended by these muscles like a swing. On the right side, the sphenomandibular ligament between the lateral pterygoid
and the medial pterygoid as well as the lingual nerve are visible.

Trismus can make it impossible to open or close the mouth. Abscesses in the facial compartments of
the masticatory muscles can result in the mouth being locked in a close position. Excessive yawning
movements, extreme mouth opening, or accidents can cause a lockjaw with the mouth being locked
in the open position.

Clinical Remarks

Topography
Vessels and nerves of head and neck

Fig. 8.70
Vessels and nerves of head and neck, lateral superficial regions, right side; lateral view.
Superficial arteries in the area of the face are the facial artery and its branches and the parietal branch and frontal branch
of the superficial temporal artery, which originates from the external carotid artery in the lateral head region. The blood
drains from here through identically named veins into the external jugular vein.
The terminal branches of the facial nerve [VII] are the superficial nerves radiating from the intraparotid plexus located
within the parotid gland (temporal, zygomatic, buccal branches, marginal mandibular branch, cervical mandibular branch).
In front of the auricle the auriculotemporal nerve, a branch of the trigeminal nerve [V], ascends. The supra-orbital
nerve, also a branch of the trigeminal nerve [V], leaves the orbit and pierces the orbicularis oculi.
Neck and occiput receive sensory innervation from branches of the cervical plexus which largely derive from the punctum
nervosum (ERB's point) at the posterior margin of the sternocleidomastoid: the transverse cervical nerve, greater auricular
nerve, lesser occipital nerve, and supraclavicular nerves.

Fig. 8.71
Vessels and nerves of the head and neck, lateral deep regions, right side; lateral view.
Upon removal of the facial muscles and the superficial parts of the parotid gland, the course of the facial artery and the
origin of the terminal branches of the facial nerve derived from the infraparotid plexus become visible. Also shown are the
terminal sensory branches of the trigeminal nerve [V] which originate from its three parts:
• supraorbital and supratrochlear nerves (from ophthalmic nerve [V/1])

• infraorbital nerve (from maxillary nerve [V/2])

• mental nerve (from mandibular nerve [V/3])

In the lateral triangle of the neck at the posterior side of the sternocleidomastoid, the four cervical branches exit at the
ERB's point:
• transverse cervical nerve

• great auricular nerve

• lesser occipital nerve

• supraclavicular nerves
The transverse cervical nerve receives motor fibers via the cervical branches of the facial nerve [VII] for the innervation of
more distal parts of the platysma. Further, in the lateral triangle of the neck the accessory nerve [XI] runs from the
posterior border of the sternocleidomastoid to the anterior border of the trapezius. The occiput receives sensory
innervation through the greater occipital nerve (branch of the cervical plexus) and blood supply through the occipital
artery and vein.

Extirpation of lymph nodes in the lateral triangle of the neck can result in lesions of the accessory
nerve [XI] and partial palsy of the trapezius (almost always the trapezius is also innervated by the
cervical plexus – in 6.4% of cases exclusively by this plexus) which results in shoulder dysfunctions.

Clinical Remarks

Vessels and nerves of the lateral facial region

Fig. 8.72
Vessels and nerves of the head, lateral deep regions, right side; lateral view.
Upon removal of large parts of the parotid gland, the structures of the retromandibular fossa in the deep lateral head
region become visible.
Below the auricle, the undivided stem of the facial nerve [VII] is visible. Shortly after exiting the stylomastoid foramen, the
facial nerve [VII] provides branches to the digastric, posterior belly (digastric branch), to the stylohyoid (stylohyoid branch),
and to the auricular muscles (posterior auricular nerve).
Beneath the digastric and stylohyoid, the internal and external carotid arteries ascend. Together with the retromandibular
vein and the auriculotemporal nerve, the external carotid artery runs in the retromandibular fossa and branches into the
occipital, posterior auricular, maxillary, and superficial temporal arteries as well as multiple small branches. The masseter
was cut and folded backwards to demonstrate its supplying structures located on the back of this muscle (masseteric nerve
– branch of the mandibular nerve [V/3]; masseteric artery – branch of the maxillary artery). These supplying structures
reach this muscle through the mandibular notch. In the lower facial region, all mimic muscles were removed from the
mandible; the mandibular canal, which runs within the bone from the mandibular foramen to the mental foramen, was
opened up to display the inferior alveolar nerve and the corresponding artery. At the mental foramen, this nerve becomes
the mental nerve.
Below the orbit, the facial artery was partly removed. This artery continues as angular artery below the eye and in the orbit
it anastomoses with branches of the ophthalmic artery. On top of the buccinator, the sensory buccal nerve, a branch of the
mandibular nerve [V/3], is visible.

Maxillary Artery

Fig. 8.73
Arteries and nerves of the head, lateral deep regions, right side; lateral view.
In most cases, the maxillary artery courses behind the ramus of mandible. Only rarely does the artery run laterally to the
ramus. The maxillary artery continues through the masticatory muscles, supplies these muscles with blood, and provides
branches to the buccinator and the mandible. Its terminal branches reach the orbit, nose, maxilla, and palate. The external
carotid artery and its branches course through the retromandibular fossa. The facial artery was removed at the level of
the body of mandible. Normally, the pulse of the facial artery is palpable where it bends around the edge of the mandible.

Figs. 8.74a to d
Variations of the course of the maxillary artery.
 a Course of the maxillary artery medial of the lateral pterygoid and medial to the lingual and inferior alveolar nerve

b Course of the maxillary artery between the lingual nerve and the inferior alveolar nerve

c Course of the maxillary artery through a loop of the inferior alveolar nerve

d Branching of the medial meningeal artery distal of the bifurcation of the inferior alveolar artery

Branches of the Maxillary Artery

Retromandibular part • Deep auricular artery

• Anterior tympanic artery

• Inferior alveolar artery

– dental branches

– peridental branches

– mental branch

– mylohyoid branch

• Medial meningeal artery

• Pterygomeningeal artery

Intermuscular part • Masseteric artery

• Anterior deep temporal artery

• Posterior deep temporal artery

• Pterygoid branches

• Buccal artery

Sphenopalatine part • Posterior superior alveolar artery

– dental branches

– peridental branches

• Infraorbital artery

– anterior superior alveolar arteries

– dental branches

– peridental branches

• Artery of pterygoid canal

• Descending palatine artery

• Sphenopalatine artery

Pterygoid plexus
Fig. 8.75
Vessels and nerves of the head, lateral deep regions, right side; lateral view.
The pterygoid plexus drains the venous blood in the region of the masticatory muscles and releases it mainly into the
maxillary vein. The pterygoid plexus also connects with the facial vein via the deep facial vein and with the cavernous sinus
via the inferior ophthalmic vein.

Fig. 8.76
Branching of the mandibular nerve [V/3], right side; frontal view. [9]
The branching of the mandibular nerve [V/3] (→ Fig. 12.144 ) into the lingual nerve and inferior alveolar nerve normally
occurs between the sphenomandibular ligament and the medial part of the medial pterygoid. Then the inferior alveolar
nerve turns lateral and enters the mandibular canal lateral of the sphenomandibular ligament.

Mandibular nerve [V/3]

Fig. 8.77
Arteries and nerves of the head, lateral deepest regions, right side; lateral view.
Upon exiting the Foramen ovale, the mandibular nerve [V/3] divides into the lingual nerve, inferior alveolar nerve, buccal
nerve, and the auriculotemporal nerve and sends branches to the masticatory muscles.

Fig. 8.78
Branching of the mandibular nerve [V/3], right side; frontal view from the left side. [9]
Branching off the mandibular nerve [V/3], the lingual nerve enters the tongue from the lateral side. Shortly after leaving
the mandibular nerve [V/3], the lingual nerve is accompanied by the chorda tympani, which branches off the facial nerve
[VII] within the facial canal. The chorda tympani contains parasympathetic fibers for the submandibular ganglion as well as
gustatory fibers for the anterior two-thirds of the tongue.
Vessels and nerves
Arteries of the head

Fig. 8.79
External carotid artery (→ p. 53 ).
External carotid artery, left side; lateral view (→ p. 52 ).
The branches of the external carotid artery are listed in the table (→ p. 52 ) in their consecutive branching order.

Branches of the External Carotid Artery

1. Superior thyroid artery

– Infrahyoid branch

– Superior laryngeal artery

– Cricothyroid branch

– Sternocleido -mastoid branch

– Glandular branches

2. Ascending pharyngeal artery

– Pharyngeal branches

– Inferior tympanic artery

– Posterior meningeal artery

3. Lingual artery

– Dorsal lingual branches

– Sublingual artery

– Deep lingual artery

4. Facial artery

– Ascending palatine artery

– Tonsillar branch

– Submental artery

– Glandular branches

– Inferior labial artery

– Superior labial artery

– Nasal septal branch

– Lateral nasal branch

– Angular artery

5. Occipital artery

– Mastoid branch

– Auricular branch

– Sternocleido-mastoid branches

– Occipital branches

– Meningeal branch

– Descending branch

6. Posterior auricular artery

– Stylomastoid artery

– posterior tympanic artery

– Auricular branch

– Occipital branch

– Parotid branch

7. Superficial temporal artery

– Parotid branch

– Transverse facial artery

– Anterior auricular branches

– Zygomatico-orbital artery

– Medial temporal artery

– Frontal branch

– Parietal branch

8. Maxillary artery Mandibular part

– Inferior alveolar artery

– mental branch

– Medial meningeal artery

– superior tympanic artery

– deep auricular artery Pterygoid part

– anterior tympanic artery

– Masseteric artery

– Deep posterior and anterior temporal arteries

– Pterygoid branches

– Buccal artery

– Posterior superior alveolar artery Pterygo-palatine part

– dental branches

– peridental branches

– Infraorbital artery

– anterior superior alveolar arteries

– Descending palatine artery

– greater palatine artery

– lesser palatine arteries

– pharyngeal branch

– Sphenopalatine artery

– posterior lateral nasal arteries

– posterior septal branches

– nasopalatine artery

Terminal branches of the maxillary artery are the infraorbital artery, sphenopalatine artery, posterior
superior alveolar artery, and descending palatine artery

Veins of the head

Fig. 8.80
Internal jugular vein, left side; lateral view.
The internal jugular vein starts as a dilated extension of the sigmoid sinus at the cranial base. This vein drains the blood
from the regions of the skull, brain, face, and parts of the neck. The facial, lingual, pharyngeal, occipital, superior thyroid,
middle thyroid, and emissary veins drain blood from the superficial head region into the internal jugular vein.

The pulse of the jugular vein (jugular pulse) provides useful information on the venous blood
pressure and the wave-like characteristic of the jugular pulse reflects the function of the right heart.

In rare cases, inflammations in the facial area can spread via the valve-free angular vein to
intraorbital veins (superior ophthalmic vein) and eventually from there to the cavernous sinus. This
results in a life-threatening phlebitis or even a venous sinus thrombosis.

Clinical Remarks

Facial nerve [VII]

Fig. 8.81
Terminal branches of the facial nerve [VII] in the face, left side; lateral view. [8]
Within the parotid gland, the facial nerve [VII] (→ Fig. 12.149 ) creates the intraparotid plexus which, for clinical purposes,
is divided into a temporofacial (temporofacial part) and a cervicofacial branch (cervicofacial part). These two parts generate
the terminal branches of the facial nerve [VII]: temporal, zygomatic, buccal, marginal mandibular, and cervical branches.
Projecting dorsally behind the auricle is the posterior auricular nerve, another terminal branch of the facial nerve [VII].

Figs. 8.82a and b

Peripheral palsy of the facial nerve [VII], right side.
a Upon the request to raise the eyebrows, only the left half of the forehead displays wrinkles (loss of function of the
occipitofrontalis, sign of peripheral facial nerve palsy).

b Upon the request to tightly shut both eyes, the eye on the injured side fails to close properly (lagophthalmos). When
closing the eyes, the eyeball automatically turns upwards. Because the eyelid on the affected side fails to close properly,
the white sclera becomes visible (BELL's phenomenon).

A peripheral facial nerve palsy (→ Fig. 12.151 ) involves damage to the 2 nd motor neuron; this
damage can be located anywhere between the nucleus of facial nerve and its peripheral branches.
Causes are most frequently viral infections or nerve injuries during surgery on the parotid gland. The
so-called central (supranuclear) lesion of the facial nerve [VII] (central facial nerve palsy) is the
result of a damage to the 1 st motor neuron, mainly caused by bleedings or infarctions in the area of
the corticonuclear tract of the inner capsule on the contralateral side. As the temporal branches of the
facial nerve [VII] contain fibers derived from the nuclei located on the contra- and ipsilateral side, the
 muscles of the forehead and the orbicularis oculi in the upper eyelid region can still contract on both
sides. However, on the contralateral side the muscles innervated by the zygomatic, buccal, marginal
mandibular, and cervival branches are paralysed (so-called lower facial nerve palsy).

Clinical Remarks

Skin innervation

Fig. 8.83
Branches of the trigeminal nerve [V], left side; lateral view. [8]
Upon exit from the cranium, the three major branches of the trigeminal nerve [V], ophthalmic nerve [V/1], maxillary nerve
[V/2], and mandibular nerve [V/3], subdivide into smaller branches in a specific topographic order. Visible branches of the
ophthalmic nerve [V/1] are the supraorbital, supratrochlear, lacrimal, infratrochlear nerves and the external nasal
branches. The maxillary nerve [V/2] provides the infraorbital and zygomatic nerves with its zygomaticotemporal and
zygomaticofacial branches as shown in the image. Branches of the mandibular nerve [V/3] are the buccal, lingual, inferior
alveolar, and auriculotemporal nerves. When leaving the mandibular canal, the mental nerve represents the terminal
branch of the inferior alveolar nerve.

Fig. 8.84
Skin innervation of the head and neck, right side; lateral view.
The view from ventral is depicted in → Fig. 12.146 .
 As part of the physical examination of a patient, the trigeminal nerve [V] is tested by applying
pressure on the three exit points (trigeminal pressure points). Patients should not show signs of
increased sensitivity or pain at the supraorbital foramen/supraorbital notch, infraorbital foramen, or
mental foramen.

Trigeminal neuralgia (tic douloureux) is a complex and painful dysfunction of the sensory
trigeminal root. Typically located in the innervation areas of the mandibular nerve [V/3] and
maxillary nerve [V/2], the facial pain can be intense and occur quite suddenly. Touch of the skin in the
corresponding facial areas often triggers an attack.

Clinical Remarks

Lymph vessels and lymph nodes of the head

Fig. 8.85
Superficial lymph vessels and lymph nodes of the head and neck of a child, left side; lateral view.
The regional submental, submandibular, parotid, mastoid, and occipital lymph nodes collect the lymphatic fluid of the face,
scalp, and occiput. From here, the lymph is drained into superficial lateral and superior and inferior deep lateral
cervical lymph nodes (→ Fig. 11.75 ).
An important deep cervical lymph node is the jugulodigastric lymph node located between the anterior margin of the
sternocleidomastoid and the mandibular angle at the lower border of the parotid gland.
The parotid lymph nodes are divided into superficial and deep nodes. The latter include the pre-auricular, infra-auricular,
and intraglandular lymph nodes. In addition, there are isolated facial lymph nodes (buccinator, nasolabial, mandibular,
malar lymph nodes) and lymph nodes of the tongue.

Lymph Nodes of the Head

• Occipital lymph nodes

• Mastoid lymph nodes

• Superficial parotid lymph nodes

• Deep parotid lymph nodes

– preauricular lymph nodes

– infraauricular lymph nodes

– intraglandular lymph nodes

• Facial lymph nodes

– buccinator lymph node

– nasolabial lymph node

– malar lymph node

– mandibular lymph node

• Submental lymph nodes

• Submandibular lymph nodes

• Lingual lymph nodes

Deep lymph vessels of the neck

Fig. 8.86
Deep lymph nodes of the neck, right side; lateral view.
Cervical lymph nodes of both the anterior and lateral aspects of the neck are divided into a superficial and deep lymph
node compartment. The infrahyoid lymph nodes with the prelaryngeal, thyroid, pretracheal, paratracheal, and
retropharyngeal lymph nodes constitute the anterior deep cervical lymph nodes.
The lateral deep cervical lymph nodes are divided into an upper group, composed of the jugulodigastric, lateral, and
anterior lymph node, and a lower group with the juguloomohyoid and lateral lymph node and anterior lymph nodes. In
addition, there are the supraclavicular and accessory lymph nodes (in association with the accessory nerve [XI]) with the
retropharyngeal lymph nodes.

Nose
Nasal skeleton

Fig. 8.87
Nasal skeleton; frontal view.
The nasal skeleton consists of a bony and a cartilaginous part. Connective tissue fixes the cartilaginous part to the piriform
aperture which is composed of the nasal and maxillary bone. The individual elements consist of hyaline cartilage and are
linked by connective tissue. The upper lateral or triangular nasal cartilage forms the roof; the nasal tip or major alar
cartilage with a lateral crus and a medial crus creates the nasal wings. In addition, two smaller alar cartilages exist
bilaterally. At its bottom and central part, the cartilaginous part of the nasal septum supports the nasal skeleton.

Fig. 8.88
Nasal cartilages; inferior view.
The view from below shows the nasal orifices (Nares) which are delineated by the two crura of the major alar cartilage
(medial and lateral crus). In the central lower region, the cartilaginous part of the nasal septum is visible.
Fig. 8.89
Nasal skeleton; frontal view from the right side.
The cartilaginous nasal skeleton attaches to the piriform aperture by connective tissue. The lateral nasal cartilagines, major
alar, minor alar and the septal nasal cartilages are visible. There is connective tissue within the non-cartilaginous nasal
areas.

Specific clinical terms are often used: columella (anterior part of the nasal septum between the nasal
tip and the philtrum), the “keystone area” (where the nasal bone overlaps the lateral cartilages), a
soft triangle (skin area at the upper rim of the nostril, close to the point where the medial crus bends
to become the lateral crus; this cartilage-free area is composed exclusively of a skin duplication),
the “supratip area” (on the bridge of the nose just above the tip), and the weak triangle (similar
to the “supratip area” since here the bridge of the nose is exclusively formed by the septum). These
designated areas are important landmarks that require special attention by the rhinoplastic surgeon.

A hematoma of the nasal septum (e.g., as a result of a fractured nose) requires an immediate
decompression or relieve by puncture or an incision and nasal tamponade as otherwise the cartilage
will become necrotic.

Clinical Remarks

Nasal septum

Fig. 8.90
Nasal septum; view from the right side.
The septal nasal cartilage forms the frontal part of the nasal septum and extends as a long cartilaginous posterior process
between the bony parts of the nasal septum (top), composed of the perpendicular plate of the ethmoidal bone, and the
vomer (bottom).

Fig. 8.91
Inferior nasal concha, left side; frontal section at the level of the initial part of the posterior process of the septal nasal
cartilage; frontal view.
This section demonstrates the thin bony skeleton of the inferior nasal concha which is covered by a vascular plexus
(cavernous plexus) composed of a network of specialized arteries and veins. Ciliated epithelium and interspersed serous
glands (nasal glands) cover the surface of the nasal concha.

A characteristic feature of the nasal mucosa is a dense subepithelial plexus of venous sinusoids.
Depending on the particular state of swelling, approximately 35% of the nasal mucosa is composed of
vascular plexuses. The highest density of subepithelial venous plexuses is found at the lower and
middle nasal conchae and the KIESSELBACH's area of the nasal septum.

Some 80% of all humans display a nasal cycle: this refers to spontaneous alternating changes in the
swelling of the nasal mucosa in the two nasal passages lasting 2–7 hours. This alternating swelling
results in a 3-fold increase of the airway resistance in the particular nasal passage during nasal
breathing while the total nasal airway resistance remains unchanged.

Clinical Remarks

Nasal cavity
Fig. 8.92
Lateral wall of the nasal cavity, left side; lateral view.
The lateral wall of the nasal cavity is mainly occupied by the inferior and middle nasal conchae. The superior nasal
concha is small and located in close vicinity to the olfactory region at the nasal roof. Here, the olfactory nerves of the
olfactory bulb penetrate the cribriform plate and reach the neighboring mucosa, including the mucosa of the upper nasal
concha.
Keratinized stratified squamous epithelium covers the nasal vestibule. At the limen nasi, the epithelial layer transforms
into non-keratinized stratified squamous epithelium and then into ciliated pseudostratified columnar epithelium. An
imaginary line from the inferior nasal concha projects to the pharyngeal opening of the auditory tube (pharyngotympanic
tube). Above the pharyngeal opening at the pharyngeal roof lies pharyngeal tonsil.

Fig. 8.93
Nasal cavity and entrance into the paranasal sinuses, left side; view from the right side.
Beneath the anterior third of the inferior nasal concha, the nasolacrimal duct opens into the lower nasal meatus (purple
probe). Beneath the middle nasal concha, the openings of the frontal sinus (green probe), maxillary sinus (red probe),
and anterior ethmoidal cells (blue probe) are located. Beneath and behind the superior nasal concha, the posterior
ethmoidal cells (yellow probe) and the sphenoidal sinus (dark blue probe) open into the nasal cavity.

Paranasal sinuses
Fig. 8.94
Projection of the paranasal sinuses onto the skull; frontal view. [8]
The projections of the frontal and maxillary sinus as well as the ethmoidal cells are shown.

Fig. 8.95
Location of the frontal sinus and sphenoidal sinus in the skull, right side; view from the left side. [8]
The sphenoidal sinus is in close topographic relationship to the pituitary gland.

The sphenoidal sinus can extend into large areas of the sphenoidal bone. During surgical
interventions, this extensive pneumatization can endanger the internal carotid artery (internal carotid
tubercle) and the optic nerve [II] (optic nerve tubercle) because of their close proximity to the lateral
wall of the sinus.

Clinical Remarks

Paranasal sinuses, radiography

Fig. 8.96
Paranasal sinuses; radiograph of the skull with opened mouth in posterior-anterior (PA) beam projection.

Conventional radiographs provide a quick overview of the state of the paranasal sinuses. However,
computed tomography and magnetic resonance imaging have largely replaced X-ray imaging as the
diagnostic tool of choice in determining indications for surgical intervention.

Sinusitis is a frequent disease. In children, the ethmoidal sinuses are most frequently affected,
whereas in adults an inflammation of the maxillary sinuses is most often observed. Inflammations of
the ethmoidal sinuses can break through the thin orbital plate (lamina papyracea) of the ethmoidal
bone and spread into the orbit or can reach the optic canal from the posterior ethmoidal sinuses or the
sphenoidal sinus and damage the optic nerve.

Clinical Remarks

Paranasal sinuses
Fig. 8.97
Frontal section through the head at the level of the second upper molar; frontal view.
This section emphasizes the individual bilateral differences in the formation of the sectioned paranasal sinuses. On both
sides, the differently shaped maxillary sinuses display variable degrees of compartmentalization. The nasal septum
deviates to the left side (septum deviation). As a result, the lower and middle nasal conchae on the right side are markedly
more developed than on the left side. The ethmoidal cells show differences in shape between the right and left side. In the
left supraorbital region, part of the frontal sinus is visible.

Due to a severe septum deviation, nasal breathing can be markedly restricted and as a consequence
headache, hyposmia, or even anosmia may occur. The shape and size of the paranasal sinuses is
extremely variable. This accounts for interindividual as well as side differences within the same
individual and can include the complete lack of individual sinuses (aplasia).

However, individual sinuses can reach extreme sizes. If the frontal sinus extends in an occipital
direction well beyond the orbital roof (supra-orbital recess), the clinician refers to it as a
dangerous frontal sinus. An inflammatory process of the frontal sinus can overcome the thin bony
barrier and can spread into the anterior cranial fossa and lead to meningitis, epidural abscesses, or
even brain abscesses.

Clinical Remarks

Development and clinics of the paranasal sinuses

Fig. 8.98
Development of the maxillary and frontal sinuses . Y: year of life.
At about 5 years of age, the developing frontal sinus reaches the upper margin of the orbit.

Fig. 8.99
Chronic sinusitis; coronal computed tomography (CT) of the paranasal sinuses; white arrows indicate a swelling of the
inflamed mucosa in the right maxillary sinus and the ostium, while white arrow heads point to a swelling of the ethmoidal
cells. [17]

The middle nasal meatus is the endonasal access route in paranasal surgery for the treatment of a
chronic inflammation of the frontal, maxillary, and anterior ethmoidal sinuses. An unilateral
inflammation of the maxillary sinus often has an odontogenic origin (odontogenic maxillary
sinusitis). Commonly, the cause is an inflammation of the second premolar or the first molar (→ Fig.
8.35 (f35) ).

Clinical Remarks

Paranasal sinuses
Fig. 8.100
Lateral nasal wall, right side; view from the left side; nasal conchae separated from the wall at the base. [8]
The nasolacrimal duct opens into the lower nasal passage via the lacrimal fold (HASNER's valve). Beneath the middle
nasal concha, the semilunaris hiatus is shown. The ethmoidal bulla and the uncinate process are located above and below
the semilunaris hiatus, respectively. Posterior to the superior nasal concha the sphenoethmoidal recess with the opening of
the sphenoidal sinus (blue arrow) is located.
*HASNER's valve

Paranasal Sinuses – Common Clinical Terms

Agger nasi An anterior ethmoidal cell in front of and superior to the base of the middle nasal
concha

Semilunaris A crescent-shaped and up to 3 cm wide cleft between the ethmoidal bulla and the
hiatus upper free margin of the uncinate process; the semilunaris hiatus provides access to
the ethmoidal infundibulum

Ethmoidal Space delineated by the uncinate process, the lamina papyracea and the ethmoidal
infundibulum bulla

Ethmoidal bulla An anterior ethmoidal cell above the semilunaris hiatus; regularly present but may not
be found in all cases

Uncinate A thin lamellar bone of the ethmoidal bone participating in the formation of the medial
process wall of the maxillary sinus and confining the semilunaris hiatus at its anteroposterior
aspect

Basal lamella Embryonic residual lamellae present in the ethmoidal bone

There are four basal lamellae (BL):

• 1. BL: uncinate process

• 2. BL: ethmoidal bulla

• 3. BL: medial nasal concha

• 4. BL: superior nasal concha

Fontanelle Accessory opening in the medial wall of the maxillary sinus

Osteomeatal General term to describe the complex anatomy in the area around the semilunaris
complex hiatus

Frontal recess A cleft providing a connection between the frontal sinus and the main nasal cavity
(nasofrontal duct, nasofrontal canal)

HALLER's cell An ethmoidal cell assuring the pneumatization of the lower orbital wall (infraorbital
cell)

ÓNODI's cell A posterior ethmoidal cell protruding beyond the sphenoidal sinus
(spheno-
ethmoidal air
cell)

Arteries of the nasal cavity

Fig. 8.101
Nasal cavity, left side; transnasal endoscopy with 30° optics.
The examiner views the head of the middle nasal concha.
* spatula

Figs. 8.102a and b

Arteries of the nasal cavity. [8]
a Lateral wall of the right nasal cavity
b Nasal septum of the right nasal cavity
The external carotid artery provides the arterial supply to the nose. The anterior and posterior ethmoidal arteries from
the ophthalmic artery reach the lateral wall of the nose and the nasal septum by traversing through the anterior and
posterior part of the ethmoidal bone. As a terminal branch of the maxillary artery, the sphenopalatine artery gains access
to the nasal cavity through the sphenopalatine foramen. There are anastomoses via arterial vessels of the lip to the facial
artery. At the nasal septum, the sphenopalatine artery becomes the nasopalatine artery which passes through the incisive
canal to reach the oral cavity where it anastomoses with the greater palatine artery. The KIESSELBACH's area, an
arteriovenous plexus, is supplied by the nasopalatine artery and the anterior and posterior ethmoidal arteries.

The most frequent location for a nasal bleeding (epistaxis) is the KIESSELBACH's area at the nasal
septum.

Basilar skull fractures involving the cribriform plate can lead to the rupture of the anterior and/or
posterior ethmoidal arteries with consecutive nasal bleeding.

In those cases of nasal bleeding where a nasal balloon tamponade is unsuccessful, the sphenopalatine
artery has to be ligated.

Clinical Remarks

Veins and nerves of the nasal cavity

Fig. 8.103
Veins of the nasal cavity, right side; view onto the lateral nasal wall. [8]
The blood is drained via the anterior and posterior ethmoidal veins to the cavernous sinus at the base of the skull, via
the sphenopalatine vein to the pterygoid plexus in the infratemporal fossa, and via the connection to the labial veins to
the facial vein.
*connecting vein to the superior sagittal sinus via the foramen cecum (only present during childhood)
Figs. 8.104a and b
Innervation of the nasal cavity. [8]
a Lateral wall of the right nasal cavity

b Nasal septum of the right nasal cavity

Sensory innervation of the nasal mucosa is provided by branches of the trigeminal nerve [V]: ophthalmic nerve [V/1] →
anterior ethmoidal nerve and maxillary nerve [V/2] → nasal branches, nasopalatine nerve. The olfactory nerve [I]
innervates the olfactory area. The nasopalatine nerve runs alongside the nasal septum through the incisive canal, and
innervates the mucosal area of the hard palate that stretches from the backside of the incisors to the canine teeth.

As the nasal mucosa receives rich sensory innervation, each manipulation in the nose can cause
extreme pain sensations. Brain injuries with damage to the olfactory nerves can result in anosmia
(the patient is unable to smell).

Rupture of the dura mater can cause a cerebrospinal fluid rhinorrhea. A clear transparent fluid
drops from the nose of the patient. The diagnosis of cerebrospinal fluid is confirmed by the detection
of glucose using glucose test strips. A surgical intervention is mandatory to prevent an infection.

Clinical Remarks

Mouth and oral cavity

Oral cavity
Fig. 8.105
Oral cavity, right side; view from the left side.
The margins of the oral cavity are the lips (anterior), the cheeks (lateral), the muscular floor of the mouth (bottom, caudal),
and the palate (top, cranial).

Fig. 8.106
Oral cavity; frontal view; mouth open.
The oral opening (oral fissure) represents the entrance to the digestive tract and the oral cavity. The latter is divided into an
oral vestibule and the cavity proper. The borders of the oral vestibule are the lips and cheeks at the outside and the
alveolar processes and teeth at the inside. With the occlusion of teeth, a space behind the last molar tooth on each side
allows access to the oral cavity. In the region of the oropharyngeal isthmus (isthmus of fauces) the oral cavity becomes
the oral part of the pharynx (oropharynx). The excretory ducts of numerous smaller salivary glands and those of the three
paired large salivary glands all drain into the oral vestibule and the cavity proper. The body of the tongue fills large parts of
the inside of the oral cavity.
Dental arches

Fig. 8.107
Upper dental arch .
The teeth are arranged in two dental arches, the upper (maxillary or superior dental arch) and the lower dental arch
(mandibular or inferior dental arch), and are anchored in the upper and lower jaw. Dentition in the human is heterodont;
the teeth come in characteristic shapes as incisors, canines, premolars, and molars. Incisors and canine teeth are also
named front teeth, whereas premolars and molars are lateral teeth.

Fig. 8.108
Lower dental arch.
With one exception, the arrangement of teeth in the lower dental arch is similar to that in the upper dental arch. For a
precise indication of the “oral”topographic relationships, the terms “palatinal” is used in the upper jaw and “lingual” in the
lower jaw. The gingiva or gums are the part of the mucosal lining of the mouth which covers the alveolar bony processes
and the interdental bony septa, known as gingival embrasure. In addition, it covers the cervical part of the tooth and
transitions into the oral mucosal layer at the gingival margin. The gingiva supports the anchorage of the teeth and
stabilizes their position in the alveolar bone; as part of the oral mucosa, the marginal gingiva forms the junctional
epithelium which is attached to the dental surfaces.

Teeth, structure
Fig. 8.109
Incisor tooth.
Typical features of each tooth are the crown, the cervical part, and the root of the tooth. The crown of a tooth is the visible
part of a tooth, rising above the gingiva, and is covered with enamel.
The root of a tooth sits in the alveolar tooth socket, a cavity in the alveolar process of the maxilla and mandible, and is
covered with cement. Periodontal fibers (periodontium, desmodontium) anchor the root of a tooth in the alveolar bone. The
cemento-enamel junction (frequently abbreviated as CEJ) locates at the cervical part of a tooth. Here, gingival fibers
connect the gingiva with the cement of the tooth.
The deepest point in a tooth is the root apex. At the apical foramen, the dental papilla is perforated by the root canal which
provides an access route for blood vessels and nerves to the dental pulp cavity. The dental pulp cavity divides into the
radicular pulp and the coronal pulp. The dental pulp consists of connective tissue, containing blood vessels, lymph vessels,
and nerves, and thus nourishes the tooth. Similar to the dental pulp cavity, one can distinguish between radicular/root and
a coronal/crown pulp. Collectively, the cement, desmodontium, alveolar bone, and parts of the gingiva are referred to as
the parodontium.

Fig. 8.110
Permanent lower canine teeth;
an example of a tooth with one root.

Fig. 8.111
Second deciduous (milk) molar tooth;
an example of a tooth with two roots.

Fig. 8.112
First permanent upper molar tooth;
occlusal surface of a molar tooth with a detailed description of the individual parts.

Form, topography, rules for orientation

The midline is the reference line when describing the surface of a tooth. Dental structures closest
to the midline are named mesial, those located away from the midline are named distal. Contact areas
to neighboring teeth are defined as surfaces. Number, dimension, and form of the roots are
functionally adapted to the dental crown. The morphology of the roots of individual teeth in deciduous
and permanent dentition is different and variable. Teeth with a single root are the incisor, canine, and
premolar teeth. The upper premolars I and the lower molars have two roots, and the upper molars
have three roots.

Clinical Remarks

Deciduous teeth
Fig. 8.113
Milk or deciduous teeth of a three year old child; vestibular view.
A complete set of milk (deciduous) teeth is usually present at 30 months of age.

Fig. 8.114
Milk or deciduous teeth of a two year old child; upper row, vestibular view, lower row, inferior view in an oblique angle.
The medial incisors are not shown. In a two year old child, the development of the roots of the teeth is not completed in
numerous teeth. This process is only complete after dental eruption.

Dental formula

There is an internationally accepted dental formula which is applied by all disciplines of dental
medicine. Each half of a jaw (quadrant) is numbered. Starting from the midline, teeth of the
permanent and deciduous dentition are numbered consecutively from one to eight (permanent
dentition) and from one to five (deciduous dentition), respectively. The digit of the quadrant is
followed by the digit of the tooth; e.g., the description 11 (pronounced: one one) means the first incisor
in the right upper jaw of the permanent dentition; the digits 52 (pronounced: five two) means the
second incisor in the right upper jaw of the deciduous dentition.
 Clinical Remarks

Permanent teeth

Fig. 8.115
Permanent teeth; oral view.

Fig. 8.116
Permanent teeth; distal view.

Teeth are the most resistant structures in the body and serve as important evidence in forensic
medicine for the identification of a victim.

Clinical Remarks
Fig. 8.117
Permanent teeth; vestibular view.

Fig. 8.118
Permanent teeth; mesial view.

• Environmental and genetic factors can influence the dental development. Resulting dental
anomalies affect the size, form, and number of teeth.

• The administration of tetracyclines (a member of the family of antibiotics) during the phase of
dental development can result in discoloration of teeth and enamel defects.

• Also important are discolorations of teeth and enamel defects caused by high doses of fluorides in
form of tablets (dental fluorosis).

• Enamel defects can point towards hypovitaminosis D (rickets).

 • Residual elements of the odontogenic epithelium can remain as SERRE's bodies, remnants of the
epithelial root sheath as epithelial cell rests of MALASSEZ, and both can generate cysts.

Clinical Remarks

Times of tooth eruption

Fig. 8.119
Upper jaw, maxilla, with deciduous teeth and the first permanent tooth; left side: average time of tooth eruption in
months (M); right side: sequence of tooth eruption.
The development of permanent teeth (replacement teeth) and deciduous (milk) teeth is similar but happens at different
times. The time of eruption and the sequence at which milk teeth appear in the oral cavity is subject to significant
interindividual differences. However, at 30 months of age the set of deciduous teeth usually will be completed.

Fig. 8.120
Upper jaw, maxilla, with permanent teeth; left side: average time of tooth eruption in years (Y); right side: sequence of
tooth eruption.
With the exception of the molar teeth, deciduous dentition (first dentition with 20 teeth) is similar to the permanent dentition
(second dentition with 32 teeth). The sequence of eruption of the permanent molars is always the same: first molars with
six years of age (6-year molars), second molars with twelve years of age, and third molars with 18 years of age or later.

Periodontopathies are diseases affecting the supporting structures of the teeth. Parodontosis is a
chronic degenerative form of periodontal disease and results in an increased tooth mobility and tooth
loss with subsequent atrophy of the alveolar process caused by the decline of the periodontal support
system.

Systemic administration of fluoride ions during the time of enamel formation of the permanent teeth
increases the deposition of fluorapatite, instead of hydroxyapatite, resulting in a more durable
enamel capable of better resisting dental caries.
 Clinical Remarks

Development of teeth

Fig. 8.121
Upper jaw, maxilla, and lower jaw, mandible, of a five year old child; deciduous teeth and primordium of the later
permanent teeth.
Human dentition is diphyodont; there are two consecutive dentitions, known as deciduous and permanent dentition. First,
the 20 milk (deciduous) teeth form in children. Development and eruption of the first and second dentitions and the body
growth are synchronized in a timely manner. Resorption of the root of the milk teeth occurs at different time points.

Fig. 8.122
Upper jaw, maxilla, and lower jaw, mandible, of a 20 year old person .
Completion of the permanent dentition results in up to 32 permanent teeth. The third molar (serotinus; wisdom tooth) has
not yet erupted in the lower jaw. It can regress or may not have developed at all (aplasia). Usually, the molar teeth erupt
approximately seven months earlier in girls than in boys. In both sexes, the molar teeth in the lower jaw erupt earlier than
molar teeth in the maxilla. The roots of the deciduous teeth require another 16 to 26 months to develop; the roots of the
permanent teeth are fully developed only after another 1.7 to 3.5 years.

Upper jaw, radiography and blood supply to the teeth

Fig. 8.123
Upper jaw, maxilla, and lower jaw, mandible, without wisdom teeth; panoramic radiograph.

Fig. 8.124
Blood supply of the teeth. [8]
The arterial blood supply to the upper lateral teeth comes from the posterior superior alveolar artery and to the upper
front teeth from the infraorbital artery, both branches of the maxillary artery. Teeth and gingiva of the lower jaw are
supplied by the inferior alveolar artery, which runs in the mandibular canal. Concomitant veins drain the blood into the
pterygoid plexus.

Innervation of the teeth and pterygopalatine ganglion

Fig. 8.125
Innervation of the teeth, left side; lateral view.
The maxillary nerve [V/2] and mandibular nerve [V/3] of the trigeminal nerve [V] supply the sensory innervation for the
teeth. The teeth of the upper jaw are innervated by the superior dental plexus which is composed of the posterior, middle,
and anterior superior alveolar branches of the superior alveolar nerves derived from the infraorbital nerve. The teeth of the
lower jaw are innervated by the inferior dental plexus which is created by the inferior dental branches of the inferior
alveolar nerve. In addition, the front teeth in the lower jaw are innervated by the mental nerve. The innervation of the
gingiva is even more complex than the sensory innervation of the teeth. Here, the upper jaw also receives sensory fibers
from the ophthalmic nerve [V/1].

Fig. 8.126
Pterygopalatine ganglion .
Sensory nerve fibers run within the ganglionic branches of the maxillary nerve [V/2] via the pterygopalatine ganglion to
reach the soft and hard palate. Preganglionic parasympathetic fibers from the superior salivatory nucleus reach the
pterygopalatine ganglion via the facial nerve [VII] (intermediate nerve), the greater petrosal nerve, and the nerve of
pterygoid canal. In the pterygopalatine ganglion, these preganglionic parasympathetic fibers are synapsed to
postganglionic parasympathetic fibers which innervate the lacrimal glands and glands of the nose and oropharynx. These
glands receive postganglionic sympathetic fibers from the deep petrosal nerve which runs through the pterygopalatine
ganglion and derives from the internal carotid nerve (internal carotid plexus).
 Local infiltrative anesthesia is required for teeth in the upper jaw since teeth and gingiva in the
upper jaw receive their innervation from different nerve branches. A unilateral branch block
anesthetizes the teeth on the ipsilateral half of the mandible by blocking the sensory impulses of the
inferior alveolar nerve shortly before it enters the mandibular canal. Because the lingual nerve is also
anesthetized in the process, the sensory block extends to the ipsilateral half of the tongue with the
exception of the tip of the tongue. Further, the chin and parts of the lower lip are numb since all the
terminal branches of the inferior alveolar nerve are also anesthetized.

Clinical Remarks

Pterygopalatine fossa and pterygopalatine ganglion

Figs. 8.127a and b

Pterygopalatine fossa, left side; lateral view; color chart see inside of the back cover of this volume. [8]
a Overview

b Magnification

The pterygopalatine fossa represents a connecting point for the structures of the nervous system of the middle cranial
fossa, the orbit, and the nose. Maxilla, palatine bone, and sphenoidal bone participate in defining the margins of this fossa.
The borders of the pterygopalatine fossa are formed by the maxillary tuberosity in its anterior part, posterior by the
pterygoid process, medial by the perpendicular plate of the palatine bone, and cranial by the greater wing of the sphenoidal
bone. A cranial passage leads to the inferior orbital fissure providing access to the orbit. The posterior part of the
pterygopalatine fossa opens into the retropharyngeal space; its lateral opening leads into the infratemporal fossa.
*VIDIAN canal

Figs. 8.128a and b

Maxillary nerve [V/2], left side; lateral view. [8]
 a Terminal branches

b Spacial relationship to the pterygopalatine ganglion

The maxillary nerve [V/2] exits the base of the skull through the foramen rotundum to enter the pterygopalatine fossa and
exits this fossa through the infraorbital fissure. In the pterygopalatine fossa, the maxillary nerve [V/2] provides orbital
branches, the zygomatic nerve, the posterior superior alveolar nerve as well as ganglionic branches to the pterygopalatine
ganglion.

Pterygopalatine fossa

Figs. 8.129a and b

Nerve of pterygoid canal, left side; lateral view. [8]
a Overview
b Nerves in the pterygopalatine fossa
Parasympathetic fibers of the facial nerve [VII], which form the greater petrosal nerve, reach the pterygopalatine ganglion,
synapse here from preganglionic to postganglionic neurons, and run to the lacrimal, nasal, and oropharyngeal glands.
Postganglionic sympathetic fibers originating from the internal carotid plexus, assemble as the deep petrosal nerve, and
run through the pterygopalatine ganglion without synapsing in this parasympathetic ganglion. They also reach the lacrimal,
nasal, and oropharyngeal glands.

Fig. 8.130
Maxillary artery in the pterygopalatine fossa, left side; lateral view. [8]
Within the pterygopalatine fossa, the maxillary artery divides into its terminal branches: infraorbital, sphenopalatine,
posterior superior alveolar, descending palatine arteries, and pharyngeal branch.
Fig. 8.131
Veins of the pterygopalatine fossa, left side; lateral view. [8]
The infraorbital, sphenopalatine, posterior superior alveolar, and descending palatine veins drain into the pterygoid
plexus, which is located in the infratemporal fossa.

A lesion of the parasympathetic fibers exiting the brain in association with the facial nerve [VII] and
then reaching the lacrimal gland via branches of the ophthalmic nerve [V/1] can result in a reduced
production of lacrimal fluid by the lacrimal gland, leading to a dry eye syndrome (sicca syndrome).

Clinical Remarks

Palate and palatine muscles

Fig. 8.132
Hard palate and soft palate; inferior view.
The palate forms the roof of the oral cavity and the floor of the nasal cavity. It separates the oral and nasal cavities. The
hard palate and the soft palate form an anterior and posterior part, respectively.
The hard palate contributes to the phonation of consonants and serves as an abutment for the tongue when crushing
food. A number of flat palatine mucosal folds (transverse palatinal folds, palatine rugae) to both sides of the midline help
grind and pin down pieces of food against the hard palate.
The soft palate is flexible and, during swallowing, blocks off the nasopharynx by folding back onto the posterior
pharyngeal wall.
Fig. 8.133
Oral cavity and palatine muscles; view.
The palate is covered by a thick mucosal layer firmly attached to the periosteum. In its subepithelial layer, the palatine
mucosa contains packages of small mucosal glands (palatine glands). The flexible soft palate extends posterior of the hard
palate and ends in the uvula. The latter consists of a muscle (musculus uvulae) and mucosal glands. From both sides, the
palatine arches (palatoglossal arch and palatopharyngeal arch), formed by the identically named muscles, project into the
soft palate and the palatine uvula. On each side, a palatine arch frames a palatine tonsil. The palatine arches create the
pharyngeal isthmus (isthmus of fauces), the entrance to the pharynx. The passage through the isthmus of fauces is
controlled by muscles.

Varying degrees of cleft formations of the palate, upper jaw, and face result from an
insufficient mesenchymal tissue proliferation and the subsequent failure of fusion of the maxillary and
medial nasal processes. Uni- or bilateral clefting is possible and, in severe cases, a gap extends from
the upper lip through the hard and soft palate (cheilognathopalatoschisis). It occurs at a
frequency of 1 : 2500 births with a preference in females. Isolated cleft palates occur if the fusion
of the maxillary processes of the secondary palate or the fusion between the primary and secondary
palate fails. The mildest form is the split uvula (bifid uvula). These clefts are not hereditary but the
result of a deficiency in folic acid in the maternal nutrition during pregnancy (→ Clinical Remarks on
p. 84 ).

Clinical Remarks

Development of the palate and palatine muscles

Figs. 8.134a to c
Development of the palate, separation of the nasal and oral cavities . [20]
The merger of the two medial nasal prominences creates the median palatine process (intermaxillary segment) which is
the structural basis for the future philtrum of the upper lip, part of the maxilla (with the four incisors), and the future primary
palate. The primary palate extends into the anterior part of the oronasal cavity. The two opposing palatine processes of the
maxilla form the major part of the definitive bony palate. By week 7, the tongue moves into a caudal position, the opposing
palatine processes assume a horizontal position, start closing the gap between nose and mouth, and finally merge in the
midline as secondary palate. In the anterior part, these palatine processes fuse with the primary palate.

Fig. 8.135
Levator veli palatini, tensor veli palatini, and cartilage of the pharyngotympanic tube, cartilage of tube; inferior
view.
In addition to the palatoglossus and palatopharyngeus (→ Fig. 8.137 (f138) ) which facilitate the depression/pull-down of
the soft palate, and the musculus uvulae which helps empty the mucous glands of the uvula, both the tensor veli palatini
and the levator veli palatini project into the palatine aponeurosis. Both muscles attach at the base of the skull. The
pterygoid hamulus serves as a hypomochlion (center of rotation of a joint) for the tensor veli palatini. Upon contraction, this
paired muscle pulls the soft palate backwards and upwards and occludes the nasopharynx against the oropharynx
during swallowing. In addition, this muscle participates in the opening of the auditory tube (→ pp. 149 and 150 ).

Fig. 8.136
Tongue in the oral cavity; posterior lateral view.
Posterior to the sulcus terminalis lies the root of the tongue with the lingual tonsil.
The Tonsilla lingualis is part of the WALDEYER's tonsillar ring, as is the The lingual tonsil is part of the WALDEYER's
tonsillar ring, as is the palatine tonsil, which is located between the two palatine arches (palatoglossal and
palatopharyngeal arch).

Tongue
Fig. 8.137
Tongue; superior view.
On the dorsum of tongue, the midline groove (median sulcus) of tongue divides the tongue into a right and left half. The
terminal sulcus of tongue (a V-shaped groove) delineates the body of tongue from the root of tongue and separates the
tongue into an anterior (presulcal) part and a posterior (postsulcal) part. At the tip of the terminal sulcus of tongue, the
surface epithelium forms a depression, the foramen cecum of tongue. This foramen is the place where the thyroid gland
started its descent from the ectoderm of the floor of the mouth to its final destination in front of the larynx (origin of the
thyroglossal duct).
The mucosa of the anterior part is rough since it contains multiple small, partially macroscopically visible papillae (lingual,
filiform, foliate, fungiform, and vallate papillae) which play a role in the perception of touch and convey the sensory
perception of taste.
The root of tongue is covered by the lingual tonsil, framed bilaterally by the two palatine arches, palatoglossal and
palatopharyngeal arch, and posteriorly by the epiglottis. The singular median glosso-epiglottic fold and the paired lateral
glosso-epiglottic fold project from the root of tongue towards the epiglottis and delineate the epiglottic valleculae.

Fig. 8.138
Innervation and taste qualities of the dorsum of tongue .
The lingual nerve, a branch of the mandibular nerve [V/3], supplies the sensory innervation of the anterior part of the
tongue, lingual branches of the glossopharyngeal nerve [IX] supply the region of the terminal sulcus of tongue, and the
superior laryngeal nerve, a branch of the vagus nerve [X], innervates the root of tongue.
Taste sensations by the anterior two-thirds of the tongue are conveyed by branches of the facial nerve [VII] (chorda
tympani, intermediate nerve) to the upper part of the solitary tract in the brain stem; the perikarya of these sensory fibers
are located in the geniculate ganglion.
Taste sensations by the posterior third of the tongue are projected to the lower part of the solitary tract in the brain stem
by sensory fibers of the glossopharyngeal nerve [IX] and vagus nerve [X]. The perikarya of these nerve fibers reside in the
inferior ganglion of the glossopharyngeal nerve [IX] or the vagus nerve [X].
All regions within in the anterior two-thirds of the tongue are capable of perceiving all five basic qualities of taste, albeit with
different intensity. For example, the perception of “sweet” is more intense at the tip of the tongue, whereas the posterior
root of the tongue contains receptors that are particularly sensitive to a “bitter” taste.

Muscles of the tongue

Fig. 8.139
Tongue and muscles of the tongue; median section.
The tongue is a highly flexible muscular body. It is essential for chewing and swallowing, facilitates sucking, and provides
the ability to speak. In addition, the tongue has an acute sense of touch and is the organ of taste sensations. The tongue is
composed of intrinsic muscles, making up the body of the tongue, and extrinsic muscles, which have their origin at the
skeleton and project into the tongue. The extrinsic muscles of the tongue alter the position of the tongue, whereas the
intrinsic muscles change the shape of the tongue. The majority of the tongue muscles insert at the lingual aponeurosis, a
tough plate of connective tissue beneath the mucosa of the dorsum of tongue.

Fig. 8.140
Tongue and intrinsic muscles of the tongue; cross-section at the level of the tip of the tongue.
Like a wickerwork, the intrinsic muscles of the tongue are interlaced in all three dimensions. In the median plane, the
lingual septum intersects the tongue incompletely into two halves. Agonistic and antagonistic muscle facilitate the flexibility
of the tongue. To both sides at the tip of the tongue a mucous gland is present (lingual gland, BLANDIN's gland).
Fig. 8.141
Tongue and intrinsic muscles of the tongue; cross-section at the level of the middle part.
The origin and insertion sites of all intrinsic muscles of the tongue are within the tongue itself. There are the superior
longitudinal, inferior longitudinal, transverse, and vertical muscles. These muscles are interlaced and positioned
perpendicular to each other in all three dimensions. The ability of the tongue to change its shape helps during chewing,
sucking, singing, speaking, and whistling. The genioglossus belongs to the extrinsic muscles of the tongue.

Hyoid bone and hyoid muscles

Fig. 8.142
Hyoid bone; anterior superior view.
The horseshoe-shaped hyoid bone consists of a body which holds the paired greater and lesser horns.

Fig. 8.143
Hyoid bone; lateral view.
Fig. 8.144
Mouth region; lateral inferior view.
The muscular oral diaphragm consists of the two mylohyoid muscles and forms the floor of the oral cavity. In addition, the
geniohyoid (not shown) and digastric muscles participate in the formation of the floor of the mouth. Directly or indirectly, all
these muscles are attached to the hyoid bone and, together with the stylohyoid muscles, are collectively referred to as
suprahyoid muscles. From a functional standpoint, the floor of the mouth represents an adjustable abutment for the
tongue.

Touching the floor of the mouth, the palatine arches or the back of the throat initiates either the
swallowing or the gag reflex. Muscles of the tongue, pharynx, larynx, and esophagus participate in
these reflexes.

Allergic reactions can result in a life-threatening swelling of the mucosal lining of the soft palate.

Inflammations of the palatine mucosa, here particularly the mucosa of the soft palate, typically
evoke severe discomfort during swallowing.

Impaired blood perfusion of the brain stem frequently coincides with palatine muscle palsy.
This causes difficulties in swallowing and an impaired tubal ventilation of the middle ear. These
patients can display a velopalatine palsy (nuclear lesions of the glossopharyngeal nerve [IX] and vagus
nerve [X]) resulting in the soft palate hanging down on the side of the paralysed levator veli palatini.
The uvula deviates to the other (healthy) side.

Often, the tongue is the first to be injured by chemical burns and scalding. At the margins of the
tongue, potential precancerous lesions can show as hyperkeratosis or leukoplakia.

Clinical Remarks

Floor of the mouth and muscles of the floor of the mouth

Fig. 8.145
Lower jaw, mandible, and muscles of the floor of the mouth, suprahyoid muscles; frontal view.
The floor of the mouth (oral diaphragm) is a muscular layer created by the suprahyoid group of muscles. The central
muscle at the floor of the mouth is the mylohyoid which extends between the two rami of mandible to both sides and joins
in the midline at the mylohyoid raphe. Beneath this muscle lies the paired anterior belly of the digastric which connects
with the posterior belly by an intramuscular tendon. This intramuscular tendon passes through a tendinous pulley and
attaches the digastric to the hyoid bone. A third suprahyoid muscle coming from the hyoid bone is the stylohyoid.

Fig. 8.146
Lower jaw, mandible, muscles of the floor of the mouth, suprahyoid muscles, and hyoid bone; superior view.
The oral diaphragm, formed by the two mylohyoid and the paired geniohyoid muscles, is shown. The geniohyoid belongs
to the suprahyoid muscle group and stretches from the inside of the mandible to the hyoid bone. As a member of the
extrinsic muscles of the tongue, the overlying genioglossus has been cut at its origin at the superior mental spine of the
mandible.

Muscles of the tongue

Fig. 8.147
Tongue and extrinsic muscles of the tongue; view from the left side.
The extrinsic muscles of the tongue project into the tongue. They consist of the genioglossus, hyoglossus, and
styloglossus. In addition, the palatoglossus is an extrinsic muscle of the tongue. The hyoglossus can receive functional
support by a chondroglossus, which originates from the lesser horn of the hyoid bone (→ Figs. 8.148 (f149) and 8.149
(f150) ).

Fig. 8.148
Tongue and extrinsic muscles of the tongue; view from the left side.
Beneath the dissected hyoglossus, the small chondroglossus is shown originating from the lesser horn of the hyoid bone
and functionally assisting the hyoglossus. In addition to the extrinsic muscles of the tongue, the palatoglossus and the
glossopharyngeal part of the superior constrictor project into the posterior aspect of the tongue.

The protrusion of the tongue requires a functionally intact genioglossus muscle. In a deep coma, the
genioglossus becomes flaccid. In a supine position, the tongue slides back into the pharynx and can
block the airways. Thus, as a precaution unconscious patients should always be placed in the lateral
recovery position.

Clinical Remarks

Muscles of the tongue and pharynx

Fig. 8.149
Muscles of the tongue; inferior view.
The genioglossus was removed at its mandibular origin. Also, the styloglossus and palatoglossus were removed. At the
lateral side, the hyoglossus (cut at the right side of the tongue) and chondroglossus are shown, which are extrinsic
muscles of the tongue. As part of the intrinsic muscles of the tongue, the inferior longitudinal muscle stretches out within
the inferior aspect of the tongue.

Fig. 8.150
Extrinsic muscles of the tongue and pharyngeal mus-cles, constrictor muscles; lateral view; mandibular arch
removed.
The stylohyoid ligament extends between styloglossus and stylopharyngeus. Located below are the pharyngeal muscles:
the superior constrictor with the glossopharyngeal parts and the middle constrictor with the chondropharyngeal and
ceratopharyngeal parts. The inferior constrictor with the thyropharyngeal part is located below the hyoid bone.

Vessels and nerves of the tongue

Fig. 8.151
Vessels and nerves of the tongue; inferior view.
The lingual artery from the external carotid artery provides the arterial blood supply of the tongue. Branches of the lingual
artery are deep lingual artery, mainly supplying the muscles of the middle and anterior part of the tongue, and the
sublingual artery, passing to the sublingual gland and to the floor of the mouth. Projecting backwards, the dorsal lingual
branches can communicate with each other, whereas all other branches from each side are separated by the lingual
septum and only provide arterial blood to one half of the tongue.
The venous drainage is achieved by the lingual vein. The lingual vein runs adjacent to the hyoglossus and drains into the
internal jugular vein. The lingual vein collects blood from the sublingual, deep lingual, and dorsal lingual veins as well as
from the vena comitans of hypoglossal nerve.
With the exception of the innervation of the palatoglossus by the pharyngeal plexus, the motor innervation of the tongue
derives from the hypoglossal nerve [XII]. Sensory innervation in the anterior two-thirds of the tongue is provided by the
lingual nerve, a branch of the mandibular nerve [V/3], in the region of the terminal sulcus by the glossopharyngeal nerve
[IX], and at the base of the tongue by the superior laryngeal nerve (a branch of the vagus nerve [X]).
Branches of the lingual artery:
(hyoid branch)

dorsal lingual branches

suprahyoid branch

sublingual artery

deep lingual artery

A subepithelial venous plexus is located in the mucosal lining at the underside of the tongue. This
facilitates quick resorption of medication placed underneath the tongue.

Injuries to the hypoglossal nerve [XII] on one side cause the protruding tongue to deviate to the
affected side; muscular atrophy occurs on the ipsilateral side of the hypoglossal nerve palsy.

Clinical Remarks

Vessels and nerves of the tongue, tonsils

Fig. 8.152
Vessels and nerves of the tongue; lateral view; mandibular arch removed. [10]

Pharyngeal Lymphoid Ring (WALDEYER's Tonsillar Ring)

Definition A cluster of lympho-epithelial tissues located at the transitional zone between oral and
nasal cavity and the pharynx form the pharyngeal lymphoid ring. The pharyngeal lymphoid
ring serves in immune responses and is part of the mucosa-associated lymphoid tissue
(MALT).

Components • Pharyngeal tonsil → pp. 60 , 68

• Tubal tonsil

• Palatine tonsil → pp. 80 , 82

• Lingual tonsil → pp. 81 , 82

• Lateral assortment of MALT

Fig. 8.153
Blood and nerve supply of the palatine tonsil, right side; medial view.
The tonsillar branches of the ascending palatine artery, the pharyngeal branch of the descending palatine artery and the
pharyngeal branches of the ascending pharyngeal artery as well as the dorsal lingual branches of the lingual artery supply
blood to the palatine tonsil. The innervation of the tonsillar bed comes from tonsillar branches of the lesser palatine
nerves and the glossopharyngeal nerve [IX].

Frequent recurrent infection of the palatine tonsils is an indication for their surgical removal
(tonsillectomy), one of the most frequently conducted surgical ENT procedures. Postoperative
bleedings can occur up to three weeks after the operation (in rare cases even longer) and can be a
serious complication.

Clinical Remarks

Salivary glands
Parotid gland
Fig. 8.154
Parotid gland, right side; lateral view.
The exclusively serous parotid gland is the largest salivary gland. Size and dimensions are quite variable. The superficial
layer of the gland is positioned directly in front of the outer ear and covered by a tough fascia (parotid fascia; cut margins
shown).
The parotid fascia is a continuation of the superficial layer of the cervical fascia. At the anterior margin of the gland, the
parotid duct exits and runs horizontally across the upper half of the masseter to the buccinator, pierces this muscle, and, in
the papilla of parotid duct, opens into the oral vestibule opposite to the second upper molar tooth. Frequently, accessory
glandular tissue (accessory parotid gland) is associated with the excretory duct.

Surgical removal of tumors the parotid gland can result in gustatory sweating (FREY's
syndrome). During the surgery, damage occurs to the sympathetic and parasympathetic nerve fibers
innervating the glandular parenchyma. Postoperative recovery includes the regeneration of
parasympathetic fibers and the accidental synapsing of these regenerated fibers with sweat glands of
the skin, formerly innervated by sympathetic fibers. Acetylcholine is the neurotransmitter for the
sympathetic innervation of sweat glands (as it is in parasympathetic nerve endings). Thus, the
formerly sympathetic innervation of sweat glands has now turned into a parasympathetic innervation
of the same glands. Activation of the parasympathetic system (e.g. in a hungry person seeing delicious
food) results in sweating of the cheek area adjacent to the ear (thus, gustatory sweating).

Parotitis epidemica or mumps is very painful because the parotid fascia restricts the expansion of
the swollen glandular tissue.

Malignant tumors of the parotid gland can result in a lesion of the facial nerve [VII]; by contrast,
benign parotid gland tumors are the most common tumors of the parotid gland and rarely damage the
facial nerve [VII].

Clinical Remarks

Parotid gland, horizontal section

Fig. 8.155
Parotid gland and masticatory muscles; horizontal section; inferior view.
The parotid gland consists of two parts. The superficial part is located immediately in front of the outer ear. Projecting
deep into the retromandibular fossa is the larger deep part of the gland which is devoid of a fascia. This section shows the
temporalis and lateral pterygoid positioned between the parotid gland and the maxillary sinus.

Salivary Glands

Three bilateral large salivary glands and multiple small salivary glands supply saliva to the oral cavity.

Large salivary glands • Parotid gland → pp. 40 , 42 , 46 , 54 , 90 , 96

• Submandibular gland → pp. 42 , 92–96

• Sublingual gland → pp. 63 , 88 , 93–96

Small salivary glands • Lip (labial glands) → p. 68

• Cheek (buccal glands)

• Tongue (lingual glands) → pp. 83 , 95 , 96

• Palate (palatine glands) → pp. 80 , 96

• Around molars (molar glands)

Openings of the salivary glands

Fig. 8.156
Opening of the excretory duct of the parotid gland, right side; inferior view from an oblique angle.
The opening of the excretory duct of the parotid gland (parotid duct, STENSEN's duct) is located opposite to the second
molar tooth on the papilla of parotid duct in the oral vestibule.

Fig. 8.157
Opening of the excretory duct of the submandibular gland, sublingual caruncle; frontal superior view.
The excretory duct of the submandibular gland (submandibular duct, WHARTON's duct) runs at the floor of the mouth (→
Figs. 8.160 (f161) and 8.161 (f162) ), merges with the main excretory duct of the sublingual gland (greater sublingual duct),
and opens at the sublingual caruncle on both sides of the frenulum of tongue and behind the incisors into the oral cavity
proper.

Anomalies of the excretory duct system, in particular the submandibular duct, can result in the
formation of a ranula (retention cyst filled with saliva).

In kidney disease, increased levels of renally cleared substances can be detected in the saliva. Salt
(calcium phosphate as main component) deposition from the saliva can cause calculus or tartar,
particularly at the lingual side of the lower incisors, or can lead to salivary glandular stones
(sialoliths) within the excretory ducts of salivary glands. This can cause the obstruction of the duct
with episodes of salivary “colics” and swelling of the gland (so-called) salivary tumor.
 Radiation therapy of head and neck tumors can lead to the dry mouth syndrome with difficulties in
swallowing and speaking. Inflammations of the salivary glands can be acute or show a chronic
progression.

Clinical Remarks

Submandibular gland

Fig. 8.158
Submandibular gland, left side; inferior view from an oblique lateral angle.
The submandibular gland is located in the submandibular triangle. The gland has its own fascia enclosed within the
superficial cervical compartment as delineated by the superficial layer of the cervical fascia (→ p. 169 ). This gland has a
direct topographic relationship to the facial artery and vein.

Fig. 8.159
Submandibular gland and sublingual gland, left side; lateral inferior view.
The superficial glandular portion of the submandibular gland is bent backward, the mylohyoid is separated from the
mandible and folded medially. Beneath the removed muscle, the deep glandular portion of the submandibular gland and
the lingual gland, positioned parallel to the body of mandible, become visible.
Arterial supply to the glands comes from the facial, submental, and lingual arteries. The venous blood is drained by the
sublingual and submental veins into the facial vein or directly into the internal jugular vein. Regional lymph nodes are the
submental and submandibular lymph nodes.

Submandibular and sublingual glands

Fig. 8.160
Submandibular gland and sublingual gland, right side; medial view.
The sublingual gland is located above the mylohyoid and lateral to the genioglossus. The gland sometimes perforates the
floor of the mouth. The glandular body bulges out the mucosa at the floor of the mouth creating the sublingual fold which
contains multiple openings of smaller excretory ducts (minor sublingual ducts) derived from the posterior glandular part.
The lower part of the submandibular gland embraces the posterior margin of the mylohyoid in a hook-shaped manner and
extends as submandibular duct above this muscle. The lingual nerve courses between the submandibular gland and the
sublingual gland and below the submandibular duct to the tongue.

Fig. 8.161
Sublingual gland and submandibular gland; superior view.
The anterior portion of the sublingual gland contains a single larger excretory duct (major sublingual duct) which merges
with the submandibular duct superior to the hyoglossus. The merged excretory ducts open at the sublingual caruncle. The
hypoglossal nerve [XII] reaches the tongue between the hyoglossus and genioglossus.

Sialoliths are most frequently observed in the excretory duct of the submandibular gland. In a
concentrated saliva, salts form crystals that create a sialolith which can block the excretory duct.
During meals, the gland quickly increases in size and becomes painful (→ p. 92 ).

Clinical Remarks

Fig. 8.162
Vessels and nerves of the tongue and large salivary glands; frontal inferior view.
A frontal view onto the elevated tongue displays a subepithelial venous plexus on the underside of the tongue. On the right
side, the sublingual gland was reflected upwards to allow an unperturbed view of the lingual nerve and the submandibular
duct (WHARTON's duct) beneath. The hypoglossal nerve [XII] enters the tongue slightly deeper. As a frequent remnant of
the thyroid development, a pyramidal lobe, located in front of the larynx, can extend up to the hyoid bone.

Parasympathetic innervation of the glands of the head

Fig. 8.163
Parasympathetic innervation of the glands of the head by autonomic ganglia of the head ; schematic drawing.
Parasympathetic fibers originate from the superior and inferior salivatory nuclei. Preganglionic parasympathetic fibers
associate with various nerves to reach the parasympathetic ganglia of the head (otic, submandibular, sublingual,
pterygopalatine, ciliary ganglia). Here, these fibers synapse and, as short postganglionic fibers, reach their target
structures (glands). Preganglionic sympathetic fibers for the head derive from the lateral horn of the spinal cord. For the
most part, these fibers synapse in the superior cervical ganglion (upper ganglion of the sympathetic chain). Postganglionic
fibers create sympathetic plexus around arteries (e.g. internal carotid artery) and reach their destinations via blood vessels
or by associating with local nerves.
*lacrimal gland anastomosis of parasympathetic secretory fibers from the intermediate nerve of the facial nerve [VII] with
the lacrimal branch of the ophthalmic nerve [V/1] to the lacrimal gland
**EDINGER-WESTPHAL nucleus
***JACOBSON's nerve
****BLANDIN's gland

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