CRACK ADC

Applied Anatomy
29 bones of the head and neck

o 8 cranial bones
o 14 facial bones
o 1 hyoid bone (only non-articulated bone of body)
o 6 auditory ossicles (stapes, incus, malleus)
Cranium divided into 2 portions:
o Anterior Visceral:
the facial cranium, made up of derivatives of the upper end of
primitive gut and its associated branchial structures. Consists of
14 bones
includes maxilla and mandible
Intramembranous calcification
o Posterior Somatic
The neurocranium and consists of 8 bones
Forms from 3 midline bones from Endochondral bones:
o ethmoid, sphenoid, and occipital
3 pairs of lateral dermal bones (Intramembranous):
o frontal, temporal, parietal
Typically, Intramembranous bone is used to augment the
face. It is a source of bone that can be graphed to the
face. could be procured from temporal and/or parietal
bone.
Typically break up the face into thirds:
o Upper third
Super-orbital rim and frontal bone and a piece of the nasalorbital-ethmoid region
Foramen in the frontal bone is longitudinally right above or just
medial to the pupil
o Middle third
Orbit and the orbital adnexium (eyeball and associated
structures), cheekbones, and maxilla
Maxilla contains a foramen that is a midline foramen that is in the
area of the infraorbitcalled the infraorbital foramen
o Lower third
Mandible and the chin
Mandible contains a foramen on the lateral aspect of the body of
the mandible (mental foramen)
Three foramens that open in a straight line on the face:

Based on the pupil, those three foramens are

Supraorbital
Infraorbital
Mental

Face Proper
Largest bone of the facial cranium is the maxilla
Anterior visceral/Facial cranium:
o 14 bones
o Brachial structures are associated with the brachial arches
o Derivatives of upper end of the primitive gut and associated brachial
structures
Posterior somatic/Neurocranium:
o 8 bones
o Bulk of this is referred to as the calvaria
Unpaired frontal bone
Unpaired occipital bone
Paired parietal bones
o Forms from 3 midline endochondral bones:
Ethmoid
Sphenoid
Occipital
o 3 pairs of lateral dermal bones (intramembranous)
Frontal
Temporal
Parietal
Trigeminal Nerve starts in Pons and Medulla Oblongata.
It is a mixed nerve. Has both sensory and motor functions.
It is a tripartite nerve: it has three branches.
First and Second branch are purely sensory.
Third branch is sensory and motor.
Motor branch starts in middle cranial fossa, then joins the sensory branch once
it exits the foramen ovale.
Three branches arise from the ganglion
The trigeminal ganglion = semilunar ganglion = Gasserian ganglion
Ganglion is located in Meckels Cave (BOARD ?)
Sphenoid Bone
Most important as it relates to where the trigeminal nerve exits the skull are
associated with the sphenoid bone
4 foramina of interest in the sphenoid bone (transmit branches of trigeminal
nerve):
o Superior orbital fissure
V1 (ophthalmic branch)

Foramen Rotundum (Latin for the round foramen)

V2 (maxillary branch)
o Foramen ovale (Latin for the oval foramen)
V3 (mandibular branch)
o Foramen spinosum
Two wings:
o Greater and Lesser Wings.
There is a curvilinear relationship of these foramen of the sphenoid bone
o Specific portion of the sphenoid bone that contains the foramen is the
greater wing of the sphenoid bone
o

Foramina and associated structures:

Cavernous sinus
o Internal Carotid Arter
o Contains cranial nerves:
III
IV
V1 and V2
VI
o A cavernous sinus thrombosis would affect which nerves?
Anesthesia of forehead via V1.
Ocular palsy (eyeball does not move)
o How does the eyeball move?
LR6SO4
Lateral Rectus is innervated by VI
Superior Oblique is innervated by IV
All other extraocular muscles are provided by III
Superior orbital fissure
o Contains cranial nerves:
III
IV
VI
Branches of V1:
Frontal nerve
Lacrimal nerve
Nasociliary nerve
o Superior ophthalmic vein
o Superior orbital fissure syndrome:
an infection
Symptoms:
palsy of ocular muscles III, IV, VI, and V1
Inferior orbital fissure transmits
o Zygomatic nerve (branch of V2) and its branches that provide sensation
to the lateral cheek (injury results in numb cheek)
Zygomaticotemporal

o
o
o

Zygomaticofacial
Sphenopalatine branches
Inferior ophthalmic vein

Trauma to the orbit can affect:

Infraorbital nerve (runs on floor of orbit)

Maxillary front teeth become numb
Optical Canal (contained within the sphenoid bone) transmits
o Optic nerve
o Central retinal artery
Vascular constriction affects central artery of the retina.
o Ophthalmic artery
Jugular Foramen:
o BOARD ?: Cranial nerves:
IX
X
XI
Foramen ovale transmits:
o V3
o Small meningeal artery
o Small petrosal nerve
o Emissary vein
Foramen Rotundum
o Transmits V2
Foramen spinosum
o Middle meningeal artery
branch of carotid arterial system
avenue by which infects of face can gain access to the meninges
o Lymphatics
o Important because the artery that is at risk of the medial aspect of the
glenoid fossa is the middle meningeal artery
What nerve supplies sensation to the dura mater?
o Middle meningeal nerve.

Pneumonic to remember 2nd and 3rd divisions: MR. MO (max rotundum, mandibular ovale)
Cranial Nerves
I
Olfactory n
II
Optic
III
Oculomotor
IV
Trochlear
V
TG

VI

Abducens

Smell (Purely Sensory)

Sight (Purely Sensory)
Moves the eye (Motor)
Superior oblique (Motor)
Sensory nerve to the face
3 divisions: ophthalmic, max, and mandibular
mixed n. (motor + sensory)
Largest Cranial Nerve
Lateral rectus (purely motor)

VII

Facial

VIII

Vestibulocochlear

IX

Glossopharyngeal

X
XI
XII

Vagus
Accessory
Hypoglossal

Facial movement
Mixed (motor + some sensory) CHECK THIS***
In particular sensation of gestation via chorda tympani
Hearing and balance
Purely Sensory
Swallowing and elevation of the soft palate and posterior
pharyngeal wall
Mixed N.
Longest distribution in the body of ANY cranial nerve
Shoulder shrugger (purely motor)
Movement of the tongue (purely motor)

There are 6 muscles that move the eyeball: LR6 SO4 (all others are by cranial nerve
3)
Four recti muscles (medial, lateral, superior, inferior)
Two obliques (superior, inferior)
Topography things of note

Mandible

Heavy cortical plate lingually and buccally (in between, there are marrow spaces)
o Does not allow infiltration to provide pulpal anesthesia of the teeth
Composed of:
o Condyle-ramus unit
2 foramina of interest:
o mandibular
o mental
Pulpal anesthesia of mand = inferior alveolar n. (IA)
At approx. apex of PM1 and PM2 = mental foramen
o IA continues thru the foramen = incisive n.
o To remove the PM2? = anesthesize IA (pulpal anesthesia)
o To remove PM1 mental nerve, can remove w/OUT anesthetize IA
Dont want to deliver bilateral lingual anesthesia to IA to kiddos
Can perform lingual infiltration via mental n.
Some of the soln will go to the foramen and anesthetize
the incisive n.
Mental nerve breaks up into 3 branches (extension from IA?)

Maxilla

Thin cortical plate that is very porous

o Infiltration works best on maxilla due to thin cortical plate.
Mainly cancellous bone.
All the teeth on a maxilla can have pulpal anesthesia merely from infiltration
Any injection near anterior teeth will affect nasal sensation.

Cheekbone can deflect the needle.

o Most maxillary anesthesia will cause some sensory deficit of the nose and
upper lip
On the posterior aspect of the maxilla lie two plates:
o Lateral and medial pterygoid plates
o Board Q: muscle attached to lateral pterygoid plate is the superior
pharyngeal constrictor
o Board Q: muscles attached to medial pterygoid plate are the medial and
lateral pterygoid muscles
No tooth on the maxilla I cannot get numb!
There is a piriform rim that is intimately associated with the apex of the
central, lateral, and canine teeth
o Anytime you anesthetize these teeth, there will be nasal consequences
The roof of the maxillary sinus is the floor of the orbit
o There is a nerve that runs across the floor of the orbit infraorbital
nerve
o Within the infraorbital canal, branches to the first and second
premolar, the mesial-buccal root of the first molar, and the
maxillary anteriors are given off
o The branch to the premolars and the MB root of the first molar is called
the middle superior alveolar nerve (MSA)
o The branch to the anterior teeth is the anterior superior alveolar nerve
(ASA)
In the posterior maxilla, the pterygopalatine fossa, the branches to the
maxillary posterior teeth are given off
o This branch is called the posterior superior alveolar nerve (PSA)
o Guarding the entrance to the pterygopalatine fossa is the malar bone
(zygoma)
Root of the zygoma can potentially affect your ability to give
anesthesia to the posterior maxilla
Just distal to the root of the canine lies the canine fossa
Posterior aspect, you can see all the porosities
o Several foramina that transmit the PSA
o When you give a maxillary injection PSA, the depth of penetration is
16mm
o There is some vascularity associated with the posterior aspect of the
maxilla, called the pterygoid plexus
Infraorbital foramen is contained within the maxilla
o You can see from an inferior view what the maxilla looks like
Two vascular structures at posterior of maxillary:
o Pterygoid Plexus (a venous structure)
short needles are used to prevent nicking of the pterygoid plexus
o Internal Maxillary Artery
close to neck of mandible

Palate

ALWAYS ASPIRATE NEEDLE BEFORE YOU INJECT LOCAL

o if you get a positive aspiration, withdraw needle, change carpule, then
reinsert

Two nerves innervate:

o Greater palatine nerve (associated with hard palate)
o Lesser palatine nerve (associated with soft palate)
Lesser palatine foramen is poster to greater palatine foramen.
At the palatal root (lingual root) of the second molar lies the greater palatine
foramen
o Greater palatine foramen encompasses the greater palatine nerve that
sends sensations to the hard palate and distal aspect of the canine
bilaterally
o Anterior to the lesser palatine foramen
Soft palate innervation is provided by the lesser palatine nerve
o This is right next to the greater palatine, so if you anesthetize one, you
will anesthetize the other!
o Posterior to the greater palatine foramen
Palatal sensation of the premaxilla:
o Provided by the nasopalatine nerve (the nerve of the premaxilla)
Only sensory nerve that crosses the midline!
o Nasopalatine nerve is about 5-7mm posterior to the central incisors
Maxillary sinus
o Supplied by V2
o Any time you have an infection in the maxillary sinus, the pt will complain
of pain in the posterior maxillary teeth
Typically all the molars, the 2nd PM, and on occasion the 1st PM
Posterior maxilla:
o Pterygopalatine fossa
o Inferior orbital fissure
Nerve associated with pulpal sensation or premolars and anteriors
o terminal branch of V2 (Infraorbital Nerve)
ASA (anterior superior alveolar)
supplies anterior incisors and canine
MSA (middle superior alveolar)
premolars and mesiobuccal root of first molar.
PSA (posterior superior alveolar)
Travels through two small foramina to enter maxillary
off of V2 from pterygopalatine fossa
1st, 2nd, and 3rd molars

A way to anesthetize all V2 is via the greater palatine foramen.

Mandible

Composed of condyle-ramus unit (flares outwardly/laterally)

Mandibular Nerve provides sensation to teeth, mucosa, tongue AND MOTOR
INNERVATION
o Motor innervation to 8 muscles.
Muscles of mastication
medial and lateral pterygoid
masseter
temporalis
Mylohyoid
Anterior belly of digastric (posterior via CN VII)
Tensor tympani
*******Tensor Veli Palatini*****
Contains two foramina of interest:
o Mandibular foramen and the mental foramen
Lingula
o little spick of bone on the medial aspect of mandible associated with
mandibular foramen.
Pulpal anesthesia is provided by the inferior alveolar nerve (IA)
At approximately the apex of the two PMs lies the mental foramen
o IA continues through the symphysis area
o At this point the IA is called the incisive nerve
Question: To remove the second PM, what nerve should be anesthetized? IA
Question: To remove the first PM, what nerve should be anesthetized? Can
perform lingual infiltration.that means anesthetize the mental nerve, hoping
that some of the solution reaches the foramen and anesthetizing the incisive
nerve good when working on kids
o Dont want to provide bilateral sensory loss on children because they
cant swallow then
o Can remove the two first premolars and not have bilateral anesthesia
Mental nerve is a continuation of the IA that exits at the mental foramen
o Mental nerve breaks up into three branches without names

Trigeminal Nerve
Ganglion associated with trigeminal nerve (all same thing, just three different
names)
o Trigeminal ganglion
o Semilunar ganglion
o Gasserian ganglion
Most important nerve of the middle cranial fossa
Largest of all cranial nerves except optic
From the ganglion, the three great branches emerge (V1, V2, V3)
Has two roots that arise from the lateral pontine region of the ganglion:
o Sensory (portio major)
o Motor (portio minor)

Great afferent nerve of the face, of the mucous membranes of the head
(meninges, paranasal sinus, and conjunctiva of the eye), internal cranial
structures, afferent nerve of the teeth and TMJs, and the efferent
(motor) nerve of the first branchial arch
o Implies the muscles of mastication (4 muscles)
medial and lateral pterygoid, masseter, and temporalis
o Mylohyoid, Anterior Belly of Digastric, Tensor Veli palatini, Tensor
Tempani
Sensory root bears largest TG (or semilunar, Gasserian) ganglion and is like the
dorsal root ganglion of a spinal nerve
o NO nerve synapses within the ganglion
o Fold of dura mater (called Meckels cage) is site of nerve synapses
3 great branches:
o V1 (smallest division), V2, V3 (largest division)
o arise from the ganglion. It should be noted that there is 1 ganglion for
each side of the face.
****BOARD ?: Primary sensation to TMJ is the auriculotemporal nerve*****

If a pt has trigeminal neuralgia, where would you section the TG nerve?

Meckels cage
Cell bodies of Trigeminal nerve embryologically arises from the NEURAL CREST
CELLS.
The type of nerve cell in the Trigeminal nerve is a PSEUDOUNIPOLAR CELL.
Like a spinal (dorsal root) ganglion i.e. it consists of a collection of pseudo-unipolar
cells, each of which has an axon passing into the brainstem and a dendrite extending
peripherally to a sensory nerve ending.
4 Nuclei:
Main Sensory Nucleus-located in pontine tegmentum. Sensation of touch.
Spinal V Tract and Nucleus-has 3 parts: Pars oralis, Pars interpolaris, Pars
caudalis. Fibers concerned with pain and thermal sensitivity
Motor nucleus-branchiomotor component
o Muscles of mastication
o BQ: the only muscle of the soft palate supplied by the trigeminal nerve
comes off the otic ganglion (the tensor veli palatini)
Mesencephalic nucleus-responsible for proprioception/jaw position and
movement
Cranial nerve V Responsibilities
Motor:
o Muscles of mastication (masseter, temporalis, med/lat pterygoid),
mylohyoid, anterior belly of digastric, tensors tympani and veli palatini

Arch

Sensory:
o to entire face
o V1: scalp anterior to ears, mucous membranes of cranial viscera, nose and
sinuses, cornea and conjunctiva
o Board ?: obliteration of corneal reflex (blink reflex)
V1:
o Accessory muscles of mastication: mylohyoid, anterior belly of digastric,
tensor tympani and veli palatini
o Motor innervation is ONLY supplied by V3
V2:
o Sensory to the gingiva/teeth and midface: maxilla, upper lip, orbit
V3:
o Sensory to lower face: gingiva/teeth of mandible, tongue, check, lower
jaw, lip (motor)
The 3 divisions embryologically supply:
o V1 frontonasal process
o V2 maxillary process
o V3 1st branchial (pharyngeal) arch
Associations: ON FINAL AND BOARDS
Most common questions involve branchial arches 1 and 2
Arch 1 CN V
Arch 2 CN VII
Arch 3 CN IX
Arch 4 CN X/XI superior laryngeal
Arch 6 CN X/XI recurrent laryngeal

Ophthalmic division
Exclusively sensory
Smallest of the three branches
3 branches:
o Frontal branch comes out and exits onto the face and breaks into
Supraorbital
Supratrochlear
o Nasociliary smallest branch of V1
Ciliary ganglion with the long and short ciliary nerves
Anterior/posterior ethmoidal nerve
Infratrochlear nerve
o Lacrimal branch
Exits the cranium via the superior orbital fissure
If paralyzed, will have an insensate conjunctiva
Why does a pt have tearing in the eye during injection?

Stimulation of lacrimal nerve

Maxillary Division

Comes into the orbit in the inferior orbital fissure and lies in infraorbital groove
to exit via the infraorbital foramen
Ganglion is the ciliary ganglion
Exclusively sensory
Exits the skull at foramen rotundum (greater wing of sphenoid bone)
Branches into 4 regions
o Cranium (middle meningeal nerve to dura)
o Pterygopalatine fossa (maxillary nerve with pterygopalatine ganglion)
o Within infraorbital canal
o Upon the face (via infraorbital foramen)
Parasympathetic ganglion is the pterygopalatine ganglion
o Just anterior to this is the posterior superior alveolar nerve
o Located in pterygopalatine fossa
o PSA is located just anterior to the ganglion goes to 1st, 2nd, 3rd molars
While in the pterygopalatine fossa, gives off 3 branches:
o Pterygopalatine nerves
Has branches to the orbit, nose, palate, and pharynx
o PSA (supplies 3rd molar, 2nd molar, and 1st molar, EXCEPT MESIOBUCCAL
ROOT OF 1ST MOLAR)
o Zygomatic
Zygomatic nerve is in the inferior orbital fissure gives sensation to skin of
cheek bone via Zygomaticotemporal and zygomaticofacial
o Where does this come from?
Nerve of premaxilla is ultimately derived from nasopalatine nerves
Branches to the nose:
o Branches to nose pass through sphenopalatine foramen just behind the
middle nasal concha and divides into the medial and lateral posterior
superior nasal branches
o The nasopalatine nerve is a branch of the medial posterior superior nasal
branch and runs through the incisive canal to end in the incisive (or
nasopalatine) foramen, covered by the incisive papillae
o Nasopalatine foramen and incisive nerve will be seen
o Nasopalatine nerve is the only nerve that crosses the midline.
Branches to palate:
o Lesser palatine
Mucous membranes of the soft palate
o Greater palatine
Sensory to soft tissues of the palate up to the area up to the 1st
PM where it anastomoses with branches of the nasopalatine nerve
o Nasopalatine
to premaxilla
o Can you give a greater palatine injection without numbing up the soft
palate? Nope because always knock out the lesser palatine (sensory nerve
to the soft palate)

Anesthetize MSA, PSA, and Greater palatine to remove the Maxillary

first molar.
Branching within the infraorbital canal:
o Within the infraorbital canal, the branches of MSA and ASA are given
off to the anterior and premolar teeth
o MSA goes to MB root of 1st molar and both premolars
o ASA goes to canines, laterals, and central incisors
o Infraorbital nerve exits onto the face at the infraorbital foramen and
branches into three parts:
One to upper lip called superior labial
One to lateral nose called lateral/external nasal
One to lower eyelid called inferior palpebral
PSA, ASA, MSA have small terminal filament nerves called the superior dental
plexus that goes to the pulp
Within the orbit is located in the inferior orbital fissure
Look at summary chart!!!
Sensory innervation to the palate by three cranial nerves
o V: GP/LP/NP
o VII: greater petrosal
o IX: tympanic (or tonsillar) plexus or lesser petrosal
o

In the cranial cavity

In pterygopalatine fossa
Infraorbital

Meningeal
Ganglionic, zygomatic, posterior superior
alveolar
MSA, ASA

Mandibular Division
Largest branch of trigeminal nerve
Exits the skull through foramen ovale
A mixed nerve
Nervous Spinosus?
When it exits foramen ovale, it is in intimate contact above the condyle
2 roots emerge separately out of the Foramen Ovale then unite, but ultimately
split into anterior and posterior divisions
Prior to the split into anterior/posterior divisions, the otic ganglion is attached
Anterior division:
o Mostly motor with branches like
Muscles of mastication
Anterior/posterior deep temporal
Buccal (both sensory and motor to lateral pterygoid muscle)
Long Buccal with CN V (sensory and motor; DOES NOT GO TO
BUCCINATOR)
Posterior division:

Includes the following branches:

Auriculotemporal
Inferior alveolar and its terminal branches
Mental nerve
Incisive nerves
Lingual
Mylohyoid (mixed nerve; ALSO PROVIDES ACCESSORY
INNERVATION TO THE MANDIBULAR INCISOR AND
MESIAL ROOT OF MANDIBULR FIRST MOLAR)
Mandibular foramen is 1.5 to 2 cm beneath mandibular notch or 1-19mm above
the occlusal plane
o Notch can be used as site to perform Inferior alveolar block
o Inject 20 mm above mandibular notch
Sphenomandibular ligament attaches to lingula.
Stylomandibular ligament goes from Styloid process to angle of mandible.
NOTE: When it comes out of the foramen, before the split into anterior and
posterior division, it is 4.5 mm in length (what were shooting for with a Gow
Gates one shot knocks the whole mandible out)
o The distance from the sigmoid notch to the lingula is about 15 mm
o Where is the lingula located? At junction of posterior third and middle
third of the mandible
Little projection of bone above the mandibular foramen
Located 1-19mm above the occlusal surfaces of the mandibular
teeth
So if you shoot 20 mm above the occlusal surface, 99% of the
time you will get profound anesthesia (shoot 20 mm or higher)
What is the most common reason for missing the mandibular
block? You shot too low
Parotid gland receives secretomotor innervation from auriculotemporal nerve
from branches from OTIC GANLGION. Auriculotemporal nerve also supplies
sensation to TMJ. Also supplies external auditory meatus and tympanic
membrane.
Exits foramen ovale and has two ganglions associated with it:
o Otic ganglion (medial aspect of mandibular nerve that sends a twig to the
tensor veli)
o Submandibular ganglion
Before inferior alveolar nerve goes into the mandible, it sends a branch called
the mylohyoid branch
o When you do inferior alveolar nerve block, you withdraw 2/3 of the
needle you will knock out the lingual nerve
o Lingual nerve has an association with CN VII chorda tympani
o Why important? Taste to anterior 2/3 of tongue
o If have a lingual nerve dysfunction, you will have a taste disturbance on
that side
Inferior alveolar nerve exits mandible at mental foramen
o

o Supplies sensation to lower lip and chin

Difference between Gow Gates and IANB?
o 95% success rate with GG; knocks out the whole damn thing
o 80-85% success rate with IANB

Headache of meningitis is mediated by GSA fibers of trigeminal nerve.

Components of Trigeminal Nerve
Component
Branchial Motor (SVE)

Function
Muscles of mastication, tensor tympanis,
tensor (veli) palatini, mylohyoid, and anterior
belly of digastric

Other mandibular division notes

The buccal nerve: comes off the facial nerve; goes to the buccinators muscle
The long buccal nerve: comes off the mandibular nerve and provides sensory
innervation
o Also supplies motor to lateral pterygoid muscle
Auriculotemporal nerve supplies sensation to TMJ!
Cant really feel the notch, so know that mandibular foramen is 1-19 mm above
the occlusal plane
Three holes that open in a straight line on the face:
Supraorbital foramen
Infraorbital foramen
Mental foramen
Maxillary Artery
Passes horizontally between ramus of mandible and the sphenomandibular
ligament and is embedded in the pterygoid plexus of veins
1 of terminal branches of external carotid? along with superficial temporal
Has three parts:
o 1st:
Deep auricular
Anterior tympanic
Middle meningeal
Inferior alveolar
nd
o 2 :
Masseteric
Deep temporal branches to pterygoids

3rd:

PSA
Infraorbital
Descending palatine and sphenopalatine (most common source of
bleeding from max artery)
Medial to the neck of the condyle
Most common source of epistaxis (nose bleeding) is from nasopalatine artery.

Oral Surgery:
Key area to achieve anesthesia is on LOWER ARCH
Anatomical series of questions for board
o anesthetize lower arch
Where is tip of needle?
pterygomandibular space
What are the boundaries of pterygomandibular space?
medial = medial pterygoid muscle
lateral = mandibular ramus
superior = lateral pterygoid
posterior = parotid gland
What are the structures within the pterygomandibular space?
inferior alveolar nerve, artery, and vein
lingual nerve
sphenomandibular ligament
What are the relationships?:
lingual nerve is anterior and medial to inferior alveolar nerve
lingula is where sphenomandibular ligament is attached