DR Gopinath thilak . p.s 1st year postgraduate Dept.

of Oral & Maxillofacial surgery

Contents


Development Prenatal Post natal Anomalies Anatomy of mandible Muscle attachments muscles of mastication Artery, vein ,nerve supply and lymphatic drainage Applied surgical anatomy Applied anatomy of surrounding soft tissue

  

Development

Prenatal Postnatal

Prenatal Development

The cartilages and the bones of the mandibular skeleton form from embryonic neural crest cells that originate from the mid- and the hindbrain regions of the neural midfolds. These cells migrate ventrally to form the mandibular facial prominences, where they differentiate into bones and connective tissue

The first structure to develop in the region of the lower jaw is the mandibular division of the trigeminal nerve that precedes the ectomesenchymal condensation forming the first pharyngeal arch .

The mandible is derived from ossification of an osteogenic membrane at 36 to 38 days of development.

Mandibular ectomesenchyme must interact initially with the epithelium of mandibular arch before primary ossification can occur; the resulting intramembranous bone lies lateral to Meckel,s cartilage of the first pharyngeal arch.

6th week post conception- a single ossification conceptioncentre for each half of mandible arises in the region of the bifurcation of the inferior alveolar nerve and artery into mental and incisive branches.

From the primary centre ossification spreads upwards to form a trough for the developing teeth The spread of the intra membranous ossification dorsally and ventrally forms the body and ramus of the mandible

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Meckel,s cartilage becomes surrounded and invaded by bone

Ossification stops dorsally at the site that will become the mandibular lingula , where meckel,s cartilage continues into the middle ear .

10th and 14th weeks post conception- secondary conceptionaccessory cartilage appear to form the head of the condyle , part of coronoid process , and mental protuberance .

10th week post conception the condylar secondary cartilage appears as a cone shaped structure in the ramal bone .

14th week the first evidence of endochondral bone appears in the condyle region

In the mental region , on the either side of symphysis , one or two small cartilages appear and ossify which later forms the symphysis menti. menti.

The condylar growth rate increases at puberty , peaks between 121/2 and 14 years of age , and normally ceases at 20 years of age .

Post natal development

Fetal mandible


The ascending ramus of the neonatal mandible is low and wide The coronoid process is relatively large and projects well above the condyle The body is merely an open shell containing the buds and partial crown of the deciduous teeth

The mandibular canal runs low in the body

4th and 12th months after birth initial seperation of the right and the left bodies of the mandible at the midline symphysis menti is gradually eliminated . As ossification converts the syndesmosis into synostosis , uniting the two halves.

Developmentally and functionally mandible is divided into several skeletal subunits .

The growth pattern of each of these skeletal subunits is influenced by a functional matrix that acts upon the bone

The main sites of postnatal mandibular growth are at the condylar cartilages , the posterior borders of the rami, rami, and the alveolar ridges .

Any damage to the condylar cartilages restricts the growth potential .

In infant, condyles of the mandible are inclined almost horizontally, , so that the condylar growth leads to an increase in the length of the mandible rather than to increase in height. Growth follows a v shape pattern

The attachment of the elevating muscles of mastication to the buccal and the lingual aspects of the ramus and to the mandibular angle and coronoid process influences the ultimate size and proportions of these mandibular elements.

The forward shift of the growing mandibular body changes the direction of the mental foramen during infancy and childhood

Clinical implication : In infants and children - the syringe needle may be applied at right angles to the body of the mandible to enter the mental foramen . In adults: needle must be applied obliquely from behind to achieve entry.

The location of the mental foramen also alters its vertical relationship within the body of the mandible from infancy to old age .

Age changes mandibular vs maxilla



Fetal life : Initially mandible is considerably larger than maxilla . LaterLatergreater development of maxilla takes place . 8 weeks of post conception maxilla overlaps the mandible 11 week- relatively greater growth of mandible results in weekthe approx equal size of the upper and the lower jaws. 13th and 20th weeks- mand growth lags behind max weeksgrowth due to change over from Meckel,s cartilage to condylar secondary cartilage .

Birth:
The mandible tend to be retrognatic to the maxilla although the two may be equal size. Early post natal life rapid mand growth and forward displacement to establish an Angles class I maxillomandibular relationship.

Anomalies of Development
 

Agnathia Micrognathia: Micrognathia:

Pierre robin syndrome cri du chat Treacher collins syndrome Progeria downs syndrome HallermannHallermann-streiff syndrome Turner syndrome Goldenhar syndrome

Macrognathia
Congenital hemifacial hypertrophy Unilateral condylar hyperplasia

Pierre Robin syndrome

Treacher collins syndrome

Parry Romberg syndrome

Goldenhar Syndrome

Agnathia

Anatomy

Condylar head Pterygoid fovea Unerupted molar 3rd

coronoid neck

Anterior ramus and coronoid notch

Alveolar part

Oblique line

body

Base of mandible Mental tubercle Mental protuberance

Mental foramen

Coronoid process

Mandibular notch

ramus

angle

lingula Sublingual fossa

ramus

Pulaosterior border of ramus Mandibular foramen

Superior and inferior mental spines Mylohyoid line Digastric fossa Angle Submandibular fossa

Mylohyoid groove

Mandibular notch

angle

Coronoid process

Muscle Attachment

Capsule of the tmj Lateral pterygoid temporalis

buccinator

platysma masseter Depressor anguli oris mentalis Depressor labii inferioris

Pmr and Scmp Buccinator mylohyoid

Medial pterygoid

buccinator

mylohyoid

Sphenomandibular ligament

genioglossus

Stylomanbular ligament

geniohyoid

Medial pterygoid Anterior belly of digastric

Muscle of Mastication

Masseter Muscle
 

Quadrangular in shape origin: zygomatic arch and

maxillary process of zygomatic bone

Insertion: lateral surface of ramus of mandible nervesupply: anterior division of mandibular nerve

Temporalis muscle


Large fan shaped muscle fossa and temporal fascia.

Origin : Bone of the temporal Insertion :Coronoid process of

the mandible and anterior margin of the ramus of the mandible almost to the last molar tooth.

Nerve supply:
anterior division of mandibular nerve

Medial Pterygoid



Quadrangular in shape
Origin Deep Head: Superficial head: Insertion: medial surface of mandible near angle Nerve supply: main trunk of mandibular nerve

Superficial head

Deep head

Lateral Pterygoid


Thick Triangular muscle. Origin: upper head: head: lower head:

Upper head Lower head

Insertion :Capsule of the TMJ

joint in the region of attachment to articular disc and pterygoid fovea on the neck of the mandible .

Applied Surgical anatomy

The mandible is basically tubular long bone which is bent into a blunt v shape


The cortical bone is thicker anteriorly and at the lower border of mandible , while posteriorly the lower border is relatively thin.

Thus the mandible is strongest anteriorly in the midline with progressively less strength towards the condyle. condyle.

The teeth


Restoration of occlusion is the prime aim in the treatment of fractures of the mandible . The presence of the teeth is extremely helpful in the reduction and fixation of mandibular fractures Complete fracture of the body of the dentate mandible will lead to the soft tissue tear over the fracture both bucally and lingually and thus are open into oral cavity and exposed to possible infection .

The mandible is commonly fractured because of their prominent position. Forward falls will result in point of chin striking the ground Chin and body of mandible form an inviting landmark in fights.

Strength of the mandible Huelke (1961) and Hodgson(1967) Hodgson(1967) investigated into the resistance of the mandible to applied forces.

Bones fracture at sites of tensile strain, since their resistance to compressive forces is greater

Huelke (1961) shown that isolated mandible is liable to particular patterns of distribution of tensile strain when forces are applied to it

The mandible is a strong bone , the energy required to fracture it being of the order of 44.6-74.4 kg/m, which is about the 44.6kg/m, same as the zygoma and about half that for the frontal bone .(Hodgson 1967)

The inferior dental neurovascular bundle



The fibrous sheath provides considerable support for the contained vessels and nerve ,which accounts for the low incidence of permanent nerve damage after fracture.

The disposition of mandibular fracture line



Hagan and Huelke ,1961 has detailed site of injuring force

1. 2. 3.

The condylar region- most common regionThe angle 2nd most Multiple fracture more common

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Condylar region
Localisation
The zygomatic arch gives some protection to the condyle from direct trauma

Condylar injuries are usually caused by an indirect impact through the body of the mandible

Impact transmitted through the Condylar neck

Fail to cause fracture Contuse the capsular ligament Capsulitis Effusion of Inflammatory exudate or Bleeding into joint

Haemarthrosis

The articular eminence limits the extent of forward translatory movement of condyle

Due to lax capsule hypermobility, hypermobility, subluxation , or dislocation over the eminentia occurs.

fracture
 Extra capsular or subsub-

condylar fracture.

Intracapsular Head fractured within joint cavity often comminuted

Sub condylar fracture:fracture:Result of voilence to the mental prominence or contralateral body of the mandible.

The line of fracture, very significantly ,lies just above the posterioposteriosuperior insertion of the masseter muscle.

Condylar neck is the site of maximum tensile strain with anterior and anterolateral applied forces.

Importance of Meniscus in TMJ Injury Meniscus:Meniscus:- intervening disc divides articular space into Temporodiscal or superior compartment Condylodiscal or inferior compartment

Importance


Loss of Meniscus leads to eventual degenerative changes in condylar articulation. Sprintz (1966) Tearing or displacement of the meniscus may be an imp requirement for ankylosis after condylar fracture . Laskin (1977) Trauma may initiate clicking or locking in the TMJ due to incoinco-ordination of translatory movement of condyle and meniscus under influence of lateral pterygoid muscle , particularly if a tear is created in the meniscal attachments to capsule .Toller(1974)

Ramus and the Coronoid process



Fracture causes minimal displacement

Ramus of mandible - splinted by masseter

muscle on lateral aspect and medial pterygoid on deep aspect.

Coronoid process- splinted by tendinous processinsertion of temporalis muscle.

The angle of Mandible

2nd common site of fracture

Clinical angle Surgical angle Anatomical angle

Factors responsible

1.

Shape of the bone

Weakness of the angle produced by abrupt change in direction between body and ascending ramus

2. A partly erupted or unerupted wisdom teeth

3. The insertions of the masseter and medial pterygoid muscles and the anterior limit of their insertion which just lie behind 3rd molar
B

Favourable and unfavourable Fractures

Vertically favourable fracture

Lingual plate

Buccal plate

Vertically unfavourable fracture

Horizontally Favourable fracture

Horizontally unfavourable fractures

Displacement of the posterior fragment is only marked if the fracture line is unfavourable in both the planes .

Horizontally and vertically favour

Horizontally and Vertically unfavourable

Fracture of the body of the mandible



Result from direct violence .

concentrated in the 1st molar or the canine regions.

Forward the site of fracture , the more is the upward displacement of the elevators counteracted by the downward pull of mylohyoid muscle attached to mylohyoid ridge on the lingual aspect of mandible.

Multiple fractures of the mandible

Fracture of the Body and opposite angle or condyle

Bilateral sub-condylar subfractures

Antero-medial deviation or dislocation Anteroof condyle. Gross anterior open bite.

Bilateral angle fractures- Two posterior fracturesfragments are drawn upwards and forwards and anterior tooth bearing fragment is rotated downwards by infra mandibular musculature.

Bilateral body fractures

Applied anatomy of the surrounding soft tissue

The condylar region

Condyle and its capsule are covered by the Parotid gland---gland---glenoid lobe

Gland Enclosed in a capsule derived from the investing layer of the deep cervical fascia

The fasia fuses with the pericondrium and periosteum of the external auditory meatus, meatus, and also the temporal fascia behind the joint capsule at the root of the zygomatic arch .

Dissection to expose the joint carried out in close contact and direction with pericondrium and periosteum covering the anterior wall of external auditory meatus

A surgical cleft is thus created along an almost avascular plane which leads naturally to the posterior aspect of the joint capsule behind and beneath the glenoid lobe and its contained arteries , veins and nerves

Incision should follow general direction of the meatus downward , forward and inwards and not in right angle to the surface

Failure to appreciate this fact Result in transection of the cartilaginous anterior wall of the meatus and might injure tympanum .(Rowe 1982)

The temporal fascia blends with the periosteum overlying the upper border of zygomatic arch The zygomatic branches of the facial nerve crossing the arch lie immediately superficial to the periosteum. periosteum.
Superficial temporal artery and vein

Temp and zyg branch of facial nerve

hence dissection must proceed superficial to the bone and deep to the periosteum if injury to nerves to is to be avoided .

The maxillary artery will be in close medial proximity to the condylar neck Important in case of ankylosis characterised by massive bone formation in relation to the medial poles of the condyle. condyle.
Inferior alveolar artery

Maxillary artery

Lingual nerve Inferior alveolar nerve

The angle and body



Natural skin creases of neck run in a correct direction for avoiding the important underlying anatomical structure
Subcutaneous fat and superficial fascia Platysma muscle(care taken to avoid external jugular vein)

Superficial layer of deep cervical fascia

Marginal mandibular branch of facial nerve( nerve stimulator used)

Facial artery lies immediately beneath the deep cervical fascia and can be observed pulsating beneath this layer

20% cases mandibular branch of facial nerve turns upwards and accompanies the vessel, anterior branch of the posterior facial vein may also be seen transversing this area Disected away and retracted if not possible divided and ligated

Dissection contiued beneath the fascia to the inferior border of mandible

Submandibular gland and its capsule becomes evident

Lower pole of the parotid may be encountered

Dissection carried out taking care to retract nerve fibres superiorly to reach the masseter muscle

Masseter muscle sharply divided at the inferior border to expose the bone

Books of Reference
 

  

Craniofacial development, Sperber Rowe and Williams, maxillofacial injuries second edition. Mc Minns colour atlas of head and neck anatomy, Logan Bari M Oral and Maxillofacial Trauma, Raymond j.
Fonseca

Gray,s Anatomy for students, Richard L.Drake Internet source