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Lp 3

Temporo-zygomatico-pterygo-masticatory space

The muscles of mastication are a group of muscles responsible


for the chewing movement of the mandible at the
temporomandibular (TMJ) joint, they enhance the process of
eating, they assist in grinding food, and also function to
approximate the teeth. The four main muscles of mastication
originate from the surface of the skull and they attach onto the
rami of the mandible at the TMJ. The movement performed by
these muscles are elevation, depression, protrusion, retraction,
and side to side movement. Three out of the main muscles are
responsible for adduction of the mandible and one helps in the
abduction of the mandible.

Unlike the muscles of facial expression that are innervated by


the facial nerve (CN VII), the muscles of mastication are
innervated by motor branches of the mandibular division of the
trigeminal nerve (CNV3), while the main arterial supply is
derived from branches of the maxillary artery.
Muscles of mastication
The muscles of mastication can be divided into the primary muscles and secondary or accessory
muscles.

The primary muscles include:

• Masseter
• Temporalis
• Lateral pterygoid
• Medial pterygoid

The secondary or accessory muscles are:


• Buccinator
• Suprahyoid muscles (digastric muscle, mylohyoid muscle, and geniohyoid muscle)
• Infrahyoid muscles (the sternohyoid, sternothyroid, thyrohyoid, and omohyoid muscle)
Masseter
It is a rectangular muscle that covers most of the lateral aspect of the ramus. It consists of three layers
that blend anteriorly: the superficial layer, intermediate layer, and deep layer.

Origin and Insertion


The fibres of the muscle originate from the inferior zygomatic arch
and the anterior two-thirds of the zygomatic arch with a connection
to the posterior aspect of the zygomatic bone. The firers converge
inferiorly forming a tendon that inserts at the outer surface of the
mandibular ramus and the coronoid process of the mandible.

Nerve and blood supply


It is innervated by the mandibular division of the Trigeminal Nerve.
Its blood supply is derived from the masseteric artery, which
emerges from the maxillary artery.
Function
The major function of the masseter muscle is to elevate the mandible, approximate the teeth.
The intermediate and deep muscle fibres of the masseter function to retract the mandible and the
superficial fibres function to protrude the mandible. The deep fibres are important stabilisers of the
TMJ.
Temporalis
It is a fan-shaped muscle that fills the temporal fossa, with anterior fibres that have a vertical orientation, mid
fibres have an oblique orientation, and posterior fibres have more of a horizontal orientation.

Origin and Insertion


It originates from the temporal fossa to the inferior temporal line of the
lateral skull. The temporalis muscle fibres converge inferiorly forming a
tendon that exists the temporal fossa passing underneath the zygomatic
arch and inserting on the coronoid process of the mandible.
Nerve and blood supply
It is supplied by the deep temporal nerve which is a branch from the
anterior division of the mandibular nerve.
Blood supply of the temporalis muscle is from the deep temporal part of
the maxillary artery and the middle temporal branches of the superficial
temporal artery.
Function
The function of the anterior and mid fibres of the temporalis muscle is
to elevate the mandible.
The posterior fibres of the temporalis muscle function to retract the
mandible. It also contributes to side to side grinding movement.
Medial Pterygoid
The medial pterygoid muscle is a thick rectangular muscle with a superficial head and a deep head. The deep head
of the medial pterygoid is larger than the superficial head.
Origin and Insertion
The medial pterygoid muscle originates on the pterygoid process, which is a downward pointing process that extends
from the sphenoid bone. The superficial head of the medial pterygoid has its origin from the maxillary tuberosity of the
inferior maxilla and the deep head originates from the medial surface of the lateral pterygoid plate of the sphenoid bone.
The medial pterygoid muscle fibres converge inferiorly, forming a tendon that inserts on the medial ramus of the
mandible posterior and inferior to the mylohyoid groove of the mandible. The insertion of the medial pterygoid forms a
tendinous band with the insertion of the masseter called the pterygoid-masseteric sling

Nerve and blood supply


It is innervated by the branch of the main trunk of the mandibular
nerve.
Its blood is supplied by a pterygoid branch of 2nd part of the maxillary
artery.
Function
The medial pterygoid muscle functions to assist with elevation and
protrusion of the mandible. It also assists the lateral pterygoid muscle with
side to side mandibular motion to help with the grinding of food.
Lateral Pterygoid
The lateral pterygoid is a short thick muscle with two head. The upper and lower head.

Origin and Insertion


The upper head arises from the infratemporal surface and
infratemporal crest of the greater wing of the sphenoid bone. The
lower head arises from the lateral surface of a lateral pterygoid
plate of the splenoid bone.
The lateral pterygoid muscle fibres converge inferiorly, forming a
tendon that inserts into a depression; pterygoid fovea of the neck of
the condylar process of the mandible along with the articular
capsule and disc of the temporomandibular articulation.

Nerve and blood supply


The lateral pterygoid is supplied by a branch of the anterior division of the mandibular nerve.
Its blood supply is from the pterygoid branch of 2nd part of the maxillary artery.

Function
The lateral pterygoid muscle functions as the sole muscle of mastication to causes depression of the
mandible. This being the case, depression of the mandible is largely the result of gravity.
It also assists with protrusion and side to side movement of the mandible.
Accessory Muscles of Mastication
Suprahyoid muscles

The suprahyoid muscle group is made up of the digastric muscle, mylohyoid muscle, and geniohyoid
muscle. They depress the mandible against resistance when infrahyoid muscles fix or depress the
hyoid bone.

Infrahyoid muscles

They are made up of the omohyoid, sternohyoid, sternothyroid, and thyrohyoid. They fix or
depresses hyoid bone.

Buccinator

The buccinator is a facial expression muscle that helps in mastication by keeping food pushed back
within the oral cavity.
The Infratemporal Fossa
The infratemporal fossa is a complex area located at the base of the skull, deep to the masseter muscle.

It is closely associated with both the temporal and pterygopalatine fossae and acts as a conduit for
neurovascular structures entering and leaving the cranial cavity.

Borders
The infratemporal fossa can be said to have a wedge shape. It is located deep to the masseter muscle and
zygomatic arch (to which the masseter attaches). The fossa is closely associated with both the pterygopalatine
fossa, via the pterygomaxillary fissure, and also communicates with the temporal fossa, which lies superiorly .

The boundaries of this complex structure consists of both bone and muscle:

Lateral – condylar process and ramus of the mandible bone


Medial – lateral pterygoid plate; tensor veli palatine, levator veli palatine and superior constrictor muscles
Anterior – posterior border of the maxillary sinus
Posterior – carotid sheath
Roof – greater wing of the sphenoid bone
Floor – medial pterygoid muscle
The roof of the infratemporal fossa, formed by the greater wing of the sphenoid bone, provides an important passage for
the neurovascular structures transmitted through the foramen ovale and spinosum. Among these are the mandibular
branch of the trigeminal nerve and the middle meningeal artery.

Contents

The infratemporal fossa acts as a


pathway for neurovascular structures
passing to and from the cranial cavity,
pterygopalatine fossa and temporal
fossa. It also contains some of the
muscles of mastication. In fact, the
lateral pterygoid splits the fossa
contents in half – the branches of the
mandibular nerve lay deep to the
muscle, while the maxillary artery is
superficial to it.
Muscles

The infratemporal fossa is associated with the muscles of mastication. The medial and lateral pterygoids are located
within the fossa itself, whilst the masseter and temporalis muscles insert and originate into the borders of the fossa.
Nerves

The infratemporal fossa forms an important passage for a number of nerves originating in the cranial cavity :

Mandibular nerve – a branch of the trigeminal


nerve (CN V). It enters the fossa via the
foramen ovale, giving rise to motor and
sensory branches. The sensory branches
continue inferiorly to provide innervation to
some of the cutaneous structures of the face.
Auriculotemporal, buccal, lingual and inferior
alveolar nerves – sensory branches of the
trigeminal nerve.
Chorda tympani – a branch of the facial nerve
(CN VII). It follows the anatomical course of
the lingual nerve and provides taste
innervation to the anterior 2/3 of the tongue.
Otic ganglion – a parasympathetic collection of
neurone cell bodies. Nerve fibres leaving this
ganglion ‘hitchhike’ along the
auriculotemporal nerve to reach the parotid
gland.
Vasculature

The infratemporal fossa contains several vascular


structures:

• Maxillary artery – the terminal branch of the


external carotid artery. It travels through the
infratemporal fossa.
Within the fossa, it gives rise to the middle
meningeal artery, which passes through the
superior border via the foramen spinosum.
• Pterygoid venous plexus – drains the eye and is
directly connected to the cavernous sinus.
It provides a potential route by which infections of
the face can spread intracranially.
• Maxillary vein
• Middle meningeal vein
The Pterygopalatine Fossa
The pterygopalatine fossa is a bilateral, cone-shaped depression extending deep from the infratemporal fossa all the way to
the nasal cavity via the sphenopalatine foramen.

It is located between the maxilla, sphenoid and palatine bones, and communicates with other regions of the skull and facial
skeleton via several canals and foramina. Its small volume combined with the numerous structures that pass through makes
this a complex region for anatomy students.

Borders

The borders of the pterygopalatine fossa are formed by the


palatine, maxilla and sphenoid bones:

Anterior: Posterior wall of the maxillary sinus.


Posterior: Pterygoid process of the sphenoid bone.
Inferior: Palatine bone and palatine canals.
Superior: Inferior orbital fissure of the eye.
Medial: Perpendicular plate of the palatine bone
Lateral: Pterygomaxillary fissure
Contents
The Pterygopalatine Fossa contains many important neurovascular structures. Here we will discuss the maxillary nerve
and its branches, the pterygopalatine ganglion and the maxillary artery and its branches.

Maxillary Nerve
The maxillary nerve is the second branch of the trigeminal
nerve (CNV2). It passes from the middle cranial fossa into the
pterygopalatine fossa through the foramen rotundum.

The main trunk of the maxillary nerve leaves the


pterygopalatine fossa via the infraorbital fissure. Here, it
enters the infraorbital canal of the maxilla and exits below the
orbit in the infraorbital foramen to contribute to the sensory
innervation of the face.

While in the pterygopalatine fossa, the maxillary nerve gives of


numerous branches including the infraorbital, zygomatic,
nasopalatine, superior alveolar, pharyngeal and the greater
and lesser palatine nerves. The maxillary nerve also
communicates with the pterygopalatine ganglion (discussed
below) via two small trunks, the pterygopalatine nerves .These
nerves suspend the ganglion within the pterygopalatine fossa.
Pterygopalatine Ganglion
The pterygopalatine ganglion sits deep within the pterygopalatine fossa near the sphenopalatine foramen. It is
the largest parasympathetic ganglion related to branches of the maxillary nerve (via pterygopalatine branches)
and is predominantly innervated by the greater petrosal branch of the facial nerve (CNVII).

Postsynaptic parasympathetic fibres leave the ganglion and distribute with branches of the maxillary nerve
(CNV2). These fibres are secretomotor in function, and provide parasympathetic innervation to the lacrimal gland,
and muscosal glands of the oral cavity, nose and pharynx.
Maxillary Artery
The maxillary artery is a terminal branch of the external carotid artery. The terminal portion of the maxillary artery lies
within the pterygopalatine fossa. Here, it separates into several branches which travel through other openings within the
fossa to reach the regions they supply.
These branches include, but are not limited to:

• Sphenopalatine artery (to the nasal cavity).


• Descending palatine artery – branches into greater and lesser palatine arteries (hard and soft palates).
• Infraorbital artery (lacrimal gland, and some muscles of the eye).
• Posterior superior alveolar artery (to the teeth and gingiva).
• At their terminal ends, the sphenopalatine and greater palatine arteries anastomose at the nasal septum.
Foramina
There are seven openings (also known as foramina) that connect the pterygopalatine fossa with the orbit, nasal
and oral cavities, middle cranial fossa and infratemporal fossa. The openings transmit blood vessels and nerves
between these regions.

Pterygomaxillary Fissure

The pterygomaxillary fissure connects the infratemporal fossa with the pterygopalatine fossa .It transmits two
neurovascular structures:

Posterior superior alveolar nerve – a branch of the maxillary nerve. It exits through the fissure into the
infratemporal fossa, where it goes on to supply the maxillary molars.
Terminal part of the maxillary artery – enters the pterygopalatine fossa via the fissure.

Foramen Rotundum

The foramen rotundum connects the pterygopalatine fossa to the middle cranial fossa. It is one of three
openings in the posterior boundary of the pterygopalatine fossa. It conducts a single structure, the maxillary
nerve.
Pterygoid and Pharyngeal Canals

These two canals, along with the foramen rotundum, are the three openings in the posterior wall of the
pterygopalatine fossa:

• Pterygoid canal – runs from the middle cranial fossa and through the medial pterygoid plate. It carries the
nerve, artery and vein of the pterygoid canal.
• Pharyngeal canal – communicates with the nasopharynx. It carries the pharyngeal branches of the
maxillary nerve and artery.

Inferior Orbital Fissure

The inferior orbital fissure forms the superior boundary of the pterygopalatine fossa and communicates with
the orbit. It is a space between the sphenoid and maxilla bones.

The zygomatic branch of the maxillary nerve and the infraorbital artery and vein pass through the inferior
orbital fissure.
Greater Palatine Canal

The greater palatine canal lies in the inferior boundary of the pterygopalatine fossa, and communicates with
the oral cavity. The canal is formed by a vertical groove in the palatine bone which is closed off by an
articulation with the maxilla. Branching from the greater palatine canal are the accessory lesser palatine
canals.

The greater palatine canal transmits the descending palatine artery and vein, the greater palatine nerve and
the lesser palatine nerve.

Sphenopalatine Foramen

This foramen is the only opening in the medial boundary. It connects the pterygopalatine fossa to the nasal
cavity – specifically the superior meatus.

It is formed by the sphenopalatine notch at the superior aspect of the perpendicular plate of the palatine bone
and the body of the sphenoid.

The sphenopalatine foramen transmits the sphenopalatine artery and vein, as well as the nasopalatine nerve
(a large branch of the pterygopalatine ganglion – CNV2).
Facial artery and vein, distribution territories

Blood Supply

The face is richly vascular, it is supplied


by :

• The facial artery


• Transverse facial
• Arteries that accompany the cutaneous
nerves
Facial Artery

It is chief artery of face


It is branch of external carotid
artery

Two parts of facial artery

1. Cervical part- runs downwards


in the neck
2. Facial part- on the face
Course
o It enters the face by winding around the base of the
mandible, by piercing th deep cervical fascia at the
antero- inferior angle of the masseter muscle.

o First it runs upwards & forwards to a point 1.25cm


lateral to the angle of the mouth.

o Then it ascends by the side of the nose up to the


medial angle of the eye, where it terminates by
anastomosing with the dorsal nasal branch of the
ophthalmic artery.

o The facial artery is very tortuous. Tortuosity of the


artery prevents its wall from being unduly stretched
during movement of mandible,lips & the cheeks.
Branches of facial part

Inferior labial – supplies lower lip

Superior labial - supplies the upper


lip & the anteroinferior part of the
nasal septum.

Lateral nasal - supplies to the ala &


dorsum of the nose.
Anastomoses

The large anterior branches


anastomoses with similar branches of
the opposite side & with the submental
artery.

At the medial angle of the eye terminal


branches of the facial artery
anastomoses with branches of the
ophthalmic artery
Transverse facial
Branch of superficial temporal artery.
•After emerging from the parotid gland, it runs forward
over the masseter between the parotid duct &
zygomatic arch.

•Accompanied by the upper buccal branch of facial


nerve.

•It supplies the parotid gland & its duct


,the masseter & overlying skin.
Venous Drainage of Face
The venous blood from the face is drained by
two veins:
 Facial vein
 Retromandibular vein

Facial Vein

Formation- it is the largest vein of the face


• At the medial angle of the eye by the
union of supratrochlear and supraorbital
veins, angular vein is formed.
• Course- The angular vein continues as the facial
vein , running downwards and backwards behind
the facial artery ,but with a straighter course at
anteroinferior angl of masseter.

• Here it pierces the deep fasia, crosses superficial to


submandibular gland and joins the anterior
division of retromandibular vein below the angle
of the mandible t form the common facial vein,
which drains into the internal jugular vein.

The facial vein communicates with the cavernous sinus


through the two routes:-
1. A communication between the supraorbital and superior
ophthalmic vein.

2. Connection with the pterygoid plexus through the deep facial


vein which passes backward over the buccinator. The
connection between facial vein and cavernous sinus is shown
in :-
facial vain – Deep facial vein
–pterygoid venous plexus– Emissary vein –cavernous sinus
NERVE SUPPLY

Each half of face has

Sensory Motor
Branches of Branches of
Trigeminal Nerve 5th Facial nerve
cranial nerve 7th cranial nerve
Sensory supply
Cutaneous innervation of the face is by
Trigeminal nerve
Areas supplied :

-Ophthalmic zone includes tip and side of


the nose, upper eye lid and forehead

-Maxillary zone upper lip, part of the side of nose, lower


eye lid, cheeks and small part of temple

-Mandibular zone include lower chin, skin overlying


mandible, part of pinna, external acoustic meatus and
temple
Facial Nerve (Motor supply)

It emerges from stylomastoid


foramen to enter the parotid gland , it
supplies all muscles of facial
expression except masseter.
It runs within substance of parotid
gland, it divides into 5 terminal
branches : Temporal
• Temporal- frontalis, auricular muscles,
orbicularis oculi
• Zygomatic- orbicularis
Zygomatic
oculi
• Buccal – muscles of cheek and upper lip
• Mandibular –muscles

Of lower lip
Buccal
• Cervical - platysma
Cervical

Mandibular
Supra nuclear lesion

•They are usually part of


hemiplegia
•Only lower part of opposite side of
face is paralysed
•Upper part of frontalis and
orbicularis oculi escapes
•due to its bilateral representation in
the cerebral cortex
Lymphatic Drainage of the Face
The face has 3 lymphatic territories-

1. Upper territory- Preauricular (parotid) nodes

Including:

• The greater part of the forehead

• Lateral halves of the eylids

• The conjunctiva

• Lateral part of the cheek

• Parotid area
Middle territory-
Submandibular nodes

• Median part of the forehead

• External nose

• Upper lip

• Lateral part of lower lip

• Medial halves of eyelids

• Medial part of cheek

• Greater part of the lower jaw

Lower territory –
Submental nodes
• Central part of the lower lip
• Chin
Parotid duct (Stensen Duct)

Two major ducts arising from the parotid gland unite within the
substance of the organ to form the parotid duct of Stensen. The
parotid duct is roughly 7 cm x 3 mm long and leaves the
superior part of the anteromedial surface of the gland. It
passes horizontally over the surface of the masseter muscle
then courses medially toward the anterior border of the
muscle. The duct then makes an abrupt right turn to cross the
buccinator muscle and associated buccal fat pad.

The parotid duct has a short submucosal course beginning at


the crown of the upper third molar, then anteriorly and
obliquely toward the upper second molar. The duct will
eventually pierce the buccal mucosa to enter the oral cavity via
a papilla adjacent to the upper second molar tooth. The
aforementioned submucosal course provides a valvular
mechanism to prevent reflux of air into the gland during
instances of raised intraoral pressure (for example, while
blowing out the cheeks).
Occasionally, there is an isolated accessory parotid gland which was historically referred to as the socia parotidis.
It, along with the transverse facial artery, rests on the superior border of the parotid duct. The accessory duct
gives off about 5 to 6 ductules that join the main parotid duct. The accessory duct is also superiorly related to the
mandibular branch of the trigeminal nerve (CN V3). The buccal branch of the facial nerve (CN VII) also travels
with the parotid duct as it goes to innervate the buccinator muscle.

Vascular supply
The arteries and veins that traverse the substance of the parotid gland are also responsible for supplying and
draining the organ. The arterial supply arises from branches of the external carotid artery, while the venous
drainage is via the retromandibular vein. Lymphatic fluid drains to the superior deep cervical lymph nodes.

Arterial supply
The branches of the external carotid artery that supply the parotid gland are the superficial temporal,
maxillary, and (indirectly) the transverse facial arteries. The external carotid artery travels parallel to the
mandible after leaving the carotid bifurcation. It continues toward the parotid gland to enter the substance of
the organ. Here, it gives off the superficial temporal and maxillary arteries (which are both terminal branches
of the external carotid artery).

The superficial temporal artery supplies the superior aspect of the gland, while the maxillary artery supplies
the medial aspect of the gland. The transverse facial artery arises off the superficial temporal artery. Not only
does it supply the parotid gland, but also the duct and nearby masseter muscle as well.
Venous drainage

The maxillary and superficial temporal veins, which travel


alongside their similarly named arteries, drain deoxygenated
blood from the parotid gland. The veins unite to form
the retromandibular vein, which traverses the substance of
the parotid gland. As it leaves the gland, it branches into
anterior and posterior counterparts.
The anterior division of the retromandibular vein descends
towards the apex of the parotid gland, where it leaves the
substance of the gland. It sometimes unites with the facial
and lingual veins, to give rise to a common facial
vein (which drains into the internal jugular vein). Similarly,
the posterior branch of the retromandibular vein leaves the
posterior border of the parotid gland. Here it may unite with
the postauricular vein before draining into the 
external jugular vein.
Lymphatic drainage

There are numerous lymph nodes distributed throughout and around the substance of the parotid
gland. This is an exception to the norm as all other salivary glands (both major and minor) do not have
lymph nodes within the glandular tissue and have far fewer nodes surrounding them. The lymph nodes
of the parotid gland are distributed throughout the superficial and deep lobes of the gland.

The majority of the lymph nodes (about 90%) are found in the superficial node. The nodes themselves
are situated close to the surface of the gland, between the capsule and glandular tissue. The superficial
set of lymph nodes drains the external acoustic meatus, auricle (pinna), scalp, eyelids, and lacrimal
glands in addition to the parotid gland. The deep set of lymph nodes also drains other structures in
addition to the parotid gland: external acoustic meatus, soft palate, middle ear, and nasopharynx.
Innervation
Every structure in the human body have interactions with the
brain through any varying combinations of cranial and
peripheral nerves. There are two major modalities that are
transmitted to and from the parotid gland - autonomic
instructions and sensory perceptions. These nerve impulses are
transmitted along cranial nerves to the gland.

So, which cranial nerve innervates the parotid salivary gland?


The gland is under parasympathetic regulation. It receives
these fibers via the lesser petrosal nerve, which is a branch of
the glossopharyngeal nerve (CN IX). Of note, CN IX synapses on
the otic ganglion. The postganglionic secretomotor fibers that
emerge from the otic ganglion reach the parotid gland via the
auriculotemporal nerve (a branch of the mandibular division of
the trigeminal nerve [CN V3]). The sympathetic supply is
derived from the adjacent sympathetic plexus of the carotid
sheath. The auriculotemporal nerve is also responsible for
carrying general visceral afferent (sensory) stimuli from the
gland as well.

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