Applied Surgical Anatomy

- Dr. Gnanasagar

Contents
Trigeminal Nerve Maxillary bone Mandibular bone Muscles of mastication

Trigeminal nerve
Largest cranial nerve Composed of 1 small motor root 1 large sensory root.
3 branches supply the skin of the ENTIRE FACE & Oral mucosa EXCEPT the pharynx & base of the tongue

Motor root
Originate within the pons & medulla oblongata Unites with the sensory root of mandibular division to form a single nerve trunk, just after their exit from the skull Supply 1. Muscles of mastication, 2. Mylohyoid, 3. Anterior belly of digastric, 4. Tensor tympani, 5. Tensor veli palatini

Sensory root
Comprise the major portion of the trigeminal (semilunar or gasserian) ganglion Ophthalmic division (V1) travels in the lateral wall of the cavernous sinus medial part of the superior orbital fissure enters the orbit Maxillary division (V2) Exits the cranium through F. rotundum Enters the upper part of pterygopalatine fossa Mandibular division (V3) Exits the skull with motor root through F. ovale Enters the infratemporal fossa

Ophthalmic division (v1)

Purely sensory Smallest of the 3 divisions 3 branches inside the orbit Nasociliary - 6 branches
Lacrimal smallest - no branches!

Frontal

largest - 2 branches

Nasociliary
1. Long ciliary iris, cornea 2. Short ciliary sensory to ciliary ganglion 3. Infratrochlear lacrimal sac & caruncle 4. Anterior ethmoidal - mucosa of the
anterior part of the nasal septum lateral wall of the nasal cavity

5. Posterior ethmoidal - ethmoidal and sphenoidal sinuses 6. External nasal - skin over nasal tip & ala.

Frontal & Lacrimal

1. Supratrochlear
conjunctiva + skin of the medial aspect of the upper eyelid the skin over the lower + mesial aspects of the forehead upper eyelid, scalp as far as the parietal bone

2. Supraorbital
-

Lacrimal - lateral part of the upper eyelid & - adjacent area of skin

Maxillary division
Purely sensory Give branches in 4 places : Within the cranium 1 branch In pterygopalatine fossa - 3 branches In the Infraorbital canal - 2 branches On the face - 3 branches

Maxillary Division
Within the cranium Middle meningeal nerve In pterygopalatine fossa
1. Zygomatic nerve 2 branches 2. Pterygopalatine nerve - 4 branches 3. Posterior superior alveolar nerve - 2 branches

In the Infraorbital canal - Infraorbital nerve

1. Middle superior alveolar (MSA) nerve 2. Anterior superior alveolar (ASA) nerve

On the face
1. Inferior palpebral branches 2. External nasal branches 3. Superior labial branches

Maxillary division
Within the cranium
Middle meningeal - sensory to duramater

In pterygopalatine fossa 1. Zygomatic nerve - enter orbit thro inferior orbital fissure & divides into i. zygomaticotemporal
- skin on the side of the forehead

ii. zygomaticofacial
- skin on the prominence of the cheek

2. Pterygopalatine nerve
1. Orbital branch - orbital periosteum 2. Nasal branch - mucosa of the superior & middle conchae, lining of the posterior ethmoidal sinuses posterior part of nasal septum Nasopalatine nerve - ant part of nasal septum & floor of the nose & palatal mucosa in the region of the premaxilla (canines to central incisors)

3. Palatine branch i. Greater palatine nerve - sensory to the palatal soft tissues & bone anterior to the first premolar ii. Lesser palatine nerve - mucosa over the soft palate

4. Pharyngeal branch - mucosa of the nasopharynx posterior to the auditory (eustachian) tube.

3. Posterior superior alveolar nerve

Usually 2 branches reach the inferior temporal surface of the maxilla 1st Supply the buccal gingiva in the maxillary molar region 2nd enters the post sup alveolar canal & supply mucosa of sinus, - 3rd,2nd, and 1st molars (alveoli, PDL, pulp) - EXCEPT the m-b root of the 1st molar in 28% of cases

 In the Infraorbital canal Here max nerve is called infraorbital nerve, 1. Middle superior alveolar (MSA) nerve 2 maxillary PM mesiobuccal root of the 1st molar PDL, buccal mucosa, bone in PM region 2. Anterior superior alveolar (ASA) nerve central & lateral incisors and the canine PDL, buccal bone, and mucous membranes of these teeth

Dental Plexus
Individual roots of all teeth, bone & PDL in both Mx+Md are innervated by the terminal branches of larger nerves in that region. These nerve networks are termed the dental plexus. Superior dental plexus for maxilla. Inferior dental plexus for mandible.

3 types of nerves emerge from these plexuses & are accompanied by a corresponding artery 1. Dental nerves, 2. Interdental branches 3. Interradicular

 Dental nerve enters the tooth through the apical foramen, supplying the pulp Interdental br.- provide sensory innervation to the PDL of adjacent teeth, the interdental papillae and buccal gingiva. Interradicular br.- provide sensory supply to the PDL of adjacent roots. Terminate in the PDL @ furcations.

 On the face: 3 branches 1. Inferior palpebral branches - the skin of the lower eyelid 2. External nasal branches - skin on the lateral aspect of the nose 3. Superior labial branches -skin and mucous membranes of the upper lip

Mandibular division (v3)

Largest branch of trigeminal nerve Mixed nerve larger sensory root & smaller motor root They unite just outside the skull and form the main trunk of the 3rd division. This trunk remains undivided for only 2 to 3 mm before it splits into a small anterior and a large posterior division

Mandibular Nerve
Give off branches in 3 areas: From undivided nerve trunk 2 br. Anterior division branches 4 br. Posterior division branches 3 br.

 From the main trunk:1. Nervus spinosus (meningeal branch of the mandibular nerve)
duramater mastoid air cells

2. Medial pterygoid nerve

motor nerve to the medial pterygoid muscle tensor veli palatini tensor tympani

 Anterior division branches: 1. Nerve to masseter 2. Nerve to temporalis 3. Nerve to lateral pterygoid 4. Buccal or long buccal or buccinator nerve
- Crosses in front of anterior border of ramus @ the occlusal level opposite to the md II or III molar - Enters cheek through the buccinator muscle - Supply buccal gingiva of the md molars & the mucobuccal fold in that region

Buccal nerve

 Posterior division branches: 1. Auriculotemporal nerve TMJ 2. Lingual nerve run anteromedial to Infr. Alv Nerve, general sensation for anterior 2/3rd of tongue mucosa of the floor of the mouth lingual gingiva enters mandibular canal thro md foramen Along with inferior alveolar artery & vein Supply pulp & buccal PD tissues of md Ms

3. Inferior alveolar nerve largest branch

Auriculotemporal nerve

 IAN divides into 2 @ the mental foramen

i. Incisive nerve remain within the canal & supply the mandibular PM, canine & incisors

ii.

Mental nerve buccal mucosa anterior to mental foramen till the midline & skin of the lower lip & chin of that side.

4. Mylohyoid nerve
-

branches from the inferior alveolar nerve before it enters the mandibular canal, a mixed nerve motor to the mylohyoid muscle & anterior belly of the digastric, sensory to the skin on the inferior & anterior surfaces of the mental protuberance & mandibular incisors.

Inferior alveolar nerve

Lingual nerve

Maxillary bone
Porous cancellous bone permits infiltration anesthesia In many areas, bone over the apices of the maxillary teeth either is paper-thin / absent (dehiscence). Posterior superior alveolar nerves & blood vessels enter the infratemporal surface of the maxilla through several alveolar canals. The maxillary tuberosity is a rounded eminence posterior to the III molar.

 Maxillary nerve passes on the superior surface of the maxilla in a groove, directed laterally and slightly superiorly, continuous with the infraorbital groove. The palatal processes of the maxilla are thick horizontal projections that form a large portion of the floor of the nose and the roof of the mouth Makes the anterior three fourths of the hard palate

Mandibular bone
Bone is Thicker on the external surface of the mandible. Thinner along the labial alveolar processes in the anterior region (incisors) permitting infiltration anesthesia. Mental foramen is in the region of the 2nd premolar on each side, midway between the upper & lower borders of the body. The mental nerve, artery & vein exit the mandibular canal through this.

Medial surface of Mandible

Ramus contains mandibular foramen
halfway between the superior and inferior borders & 2/3rd to 3/4th distance between anterior posterior border of the ramus 6-10mm above the level of mandibular occlusal plane

Coronoid notch on the anterior border of ramus represents a landmark tor determining the height of needle penetration for inferior alveolar nerve block.

 The ramus at the level of the mandibular foramen is thicker in its anterior region than posteriorly. This is of clinical importance during the inferior alveolar nerve block. The thickness of soft tissues between needle penetration and the bone of the ramus at the level of the mandibular foramen averages about 20 to 25 mm

Muscles of mastication
Muscle Masseter Origin 1. Zygomatic process of maxilla 2. Medial & infr surface of zyg bone Temporal fossa Attachment Action 1. Angle of md 1. Closes mandible, 2. Ramus 2. Clenches teeth 3. Latl surface of coronoid process 1. Coronoid process 1. Closes mandible, 2. Anterior border 2. Clenches teeth of ramus 1. Medial surface of ramus 2. Angle of mandible 1. Elevate the mandible 2. Side to side jaw movement

Temporalis

Medial Pterygoid

1. Medial surface of latl pterygoid plate 2. Palatine bone & maxillary tuberosity

Lateral Pterygoid

Superior head disc 1. Open jaw Supr head lat side 2. Protrudes md of TMJ of gr wing of sphenoid 3. Moves mandible Infr head lat side of Inferior head sidewards neck of condyle latl pterygoid plate

Muscles of mastication

Temporalis

Masseter

Medial pterygoid

Lateral pterygoid

Summary