Clinical anatomy of the head, neck and nerve pathways MUDr. Anna Rábová MANDIBULA Lower jaw §Anatomy (repetition), widespread description § § Clinical notes § § Dentoalveolar topography § § Nerve and blood supply (repetition) Ø IMG_0684- Ø -An unpaired (single) facial bone -Forms the osseous basis of the lower part of face -The only skull bone connected with the remaining skull skeleton using articultion (ATM) -The only freely movable bone of the skull -The largest and strongest bone of the skull -It also articulates with each of the maxillae by the way of lower and upper dentition - - Corpus mandibulae ØThickened along its whole lower margin – basis mandibulae and in the chin area – where it forms trigonum mandibulae (protuberantia mentalis + tubercula mentalia) – bony prominence of the chin Ø ØAlong cranial edge of mandibular body – proc. alveolaris with alveoli dentales with septa and juga alveolaria anteriorly Ø ØMental foramen Ø Ø Ø Ø ØOn the inner plane of the chin part – spina mentalis sup. et inf.– origin of m. genioglossus and m. geniohyoideus Ø ØLaterocaudally on each side – shallow pit fossa digastrica, to which venter ant. m. digastr. is attached Ø ØAn oblique margin Linea mylohyoidea passes – for attachement of m. myloh.; Ø Ø above it a shalow pit fovea sublingualis, below it fovea submandibul. – both cavities have equally named salivary glands Ø ØAngulus mandibulae: Ø ØOn external and internal side of m. angle – tuberositas for attachement of masticatory muscles Ø Ø- tuberositas masseterica -tuberositas pterygoidea Ø Ø Ramus mandibulae ØIs attached to corpus in mandibular left and right angle ØProtrudes ventrally into processus coronoideus (insertion of m. temporalis) and dorsally into proc. condylaris with cranial enlargement caput m., below it a narow neck – collum m. with central depression – fovea pteryg. (for attachement of mastic. muscle m. pteryg. later.) ØIncisura m. ØOn external surface linea obliqua protrudes caudally Ø ØTrigonum retromolare Ø - there is very porous bone – CAVE during extraction of the last molar Inner surface of ramus mandibulae mandibula 029 CAVE! Local anesthesy § Mandibular foramen § the beginning of canalis mandibulae §middleline between anterior and posterior edge of ramus § 1 cm above M3 § 2 cm behind M3 Øforamen m. - through which the neuro-vascular bundle passes into canalis m.; it is demarcated by thin osseous plate – lingula m. (attachement of lig. Sphenomandibul.) Ø ØSulcus mylohyoideus Ø Ø mandibula 029 mandibular-canal-s Mandibular canal § Is placed under the alveoli and communicates with them by small openings § § Contains the inferior alveolar nerve, artery, vein § Demarcated by the compact bone (noticeable to x-ray) § § On arriving at the incisor teeth, it turns back to communicate with the mental foramen, giving off a small canal known as the mandibular incisive canal Canalis mandib. bifidus Over 99% simple § The opening of mandibular canal § § on external side § § The position of this foramen is most frequently near the apex of the mandibular second premolar and rested between the premolars § § The foramen open upward and slightly posteriorly in adults § The foramen open straight upward in newborns § Mental foramen mandibula 009 CAVE ! Local anesthesy CT § Inner area of mentum sup. and inf. retromental for. § Unilateral, bilateral or mutliple § § In neighbourhood of mylohyoid line CAVE! Bleeding (implant placement) Lateral (accessory orifices) Incisive canal Summary 96% Demarcate of the compact bone (noticeable to x-ray) Newborn § mandibular corpus is low § the body contains the sockets of deciduous teeth (only with development and eruption of teeth proc. alveol. appears) § the angle between corpus and ramus is over 150° (widely open) § mental foramen lies on the lower edge of corpus § Mandibular body is still paired - it meets in so-called symphisis menti – it ossifies in first year of life File:Gray182.png Foramen mentale is running backward and sideways upwards - it has practical significance for local anaesthesia. When performing local anaesthesia, the puncture with needle is necessary to be directed from cranial and dorsal direction into anterior, caudal and medial direction. The lower margin of corpus mandibulae is reinforced (basis mandibulae), the reinforcement passes also onto ramus mandibulae. It is conditioned by internal modification of the bone (basal arch ), and represents a significant biomechanical factor. Below trigonum retromolare there is a very porous bone - this can be an advantage during extraction of the last molar. Increased lingula mandibulae can represent a significant obstacle, during local anaesthesia of n. alveolaris inferior. Mandibular shape changes in the course of life. In newborns, corpus mandibulae is low, foramen mentale lies on the lower edge of corpus mandibulae. Corpus mandibulae is still paired, both mandibular bases are meeting into so-called symphysis menti. Symphysis ossifies in first year of life, from the top downwards. Angulus mandibulae is obtuse – 150 to 170O (widely opened) in newborns, processus coronoideus is longer than processus condylaris. Only with development and eruption of teeth, processus alveolaris appears ; foramen mentale is projecting into the middle height of corpus mandibulae, most often below the second premolar. Angulus mandibulae is much sharper (125O), processus condylaris is elongated, and reaches the level of processus coronoideus. After loss of teeth, the corpus of mandibulae is lowered (atrophy of processus alveolaris), foramen mentale is opening at the upper margin of corpus mandibulae. The mandibular angle is increased, and its value is about 140O. From traumatological point of view, the surface position of mandible is disadvantageous. Fractures can often affect corpus mandibulae in the area of foramen mentale, mandibular angle and processus condylaris of collum mandibulae. Mandibula can also crack open during harsh teeth extraction (not only interalveolar septa) and also during surgical teeth extraction using raspatorium. Adulthood § the angle is much sharper – about 120° §condylar process is higher than the coronoid process and the sigmoid notch becomes deeper §Alveolar processus developed §Mental foramen lies in the middle of the corpus File:Gray184.png Růst Růst dolní čelisti primárně vychází z kloubní chrupavky (až do dospělosti) a z chrupavky symphysis menti (do 1. roku života), modeluje se však v podstatě periostálním růstem (udržuje se až do vysokého věku) vlivem funkčního zatížení (také dýchání, mimika, řeč, nervové a cévní zásobení, které působí stimulačně na růst). Předpokladem formativních procesů kostí je rovnováha mezi apozicí a resorpcí. DČ roste intenzivně do délky kondylárním růstem v chrupavce (dopředu a dolů). Růst doprovází na přední straně apozice, na zadní resorpce kosti.. Tato přestavba je zodpovědná za zmenšování čelistního úhlu. Růstem kloubní chrupavky se prodlužuje ramus mandibulae dozadu a nahoru a jeho úhel se zmenšuje na 120 st. Tento proces podporuje současná apozice kosti na úhlu čelisti. Apozicí kosti na zadním okraji ramena, současnou resorpcí na jeho přední hraně a vytvořením brady se čelist posouvá dopředu. Růstem těla dozadu se vytváří prostor pro stálé zuby.Na ventrálním okraji těla dolní čelisti se ukládá kost a současně vzniká alveolární část, přičemž oba procesy posouvají corpus mandibulae dolů, co se projevuje i na změně směru foramen mentale, ze kterého vystupuje cévně-nervový svazek původně svisle, ale později uhýbá dozadu a nahoru. Směr růstu dopředu a dolů se částečně kompenzuje dorzálním posunem base lebky a kloubních jamek. Brada se formuje apozicí kosti. V alveolární oblasti nad bradou se kost rezorbuje, čímž vzniká supramentální konkavita (bod supramentale v antropologii a čelistní ortopedii jako bod B). S růstemd bradového výběžku v prvních 2 letech se mění směr for. mentale: ze směru dopředu postupně nahoru a dozadu, jak je tomu u dospělého. Během remodelace čelisti dochází k resorpci vytvořené kosti (na přední ploše r. mandiublae v proc. condylaris) a současně k apozici (zadní hrany r. mandibulae). Tělo mandibuly se tak prodlužuje směrem vzad a r. mandib. se zvětšuje vertikálně a dozadu.. Čelistní aparát i proporce obličejové části lebky jsou významným způsobem ovlivněny rozvojem pr. alveolaris av souvislosti s prořezáváním doč. a st. zubů. Konec předchozího slidu: Dolní čelist je možné rozdělit na funkční jednotky, ze kterých každá má vlastní růstovou charakteristiku. 1. alveolární část, která se vytváří vlivem zubů 2. proc. coronoideus, který se formuje působením tahu m. temporalis. 3. úhel čelisti vystupuje silnější tahem masetero-pterygoidní smyčku a pr. condylaris se rozvíjí dále vlivem funkce ATM. Růst čelisti dále stimuluje jazyk, svaly spodiny ústní a hltanu a také mimické svaly. Old age § after the loss of teeth, the body is reduced + due to atrophy of the alveolar process → mandibular foramen is closer to the alveolar border § enlargement of the angle to 140° § § deepen pterygoid fovea → neck is tapered § sharp mylohyoid linea, highlighted mental spinae IMG_2286 Ve stáří Tělo bezzubé stařecké mandibuly se pomalu redukuje na podkovovitě zahnutý kostěný trámec. S atrofií alv. části se mandibulární kanál posouvá směrem nahoru. V extrémních případech může být redukována i kompaktní vrstva, která kanál ohraničuje a mandibulární kanál pak může být proti d. ústní překryt jen sliznicí. Podobně otevřený může být v oblasti řezáků canalis incisivus. To bývá příčinou bolestí vznikajících např. tlakem protézy. Linea mylohyoidea vystupuje jako ostrá hrany dovnitř a spina mentalis bývá často prodloužená. Tyto změny jsou následkem činnosti m. mylohyoideus a m. genioglossus, které tlačí jazyk proti patru při rozmělňování potravy. Oblast kostí, ke kterým jsou připojeny svaly se až do vysokého stáří nemění. Páč: po ztrátě zubů alv. i bazální část postupně atrofuje. Na straně orální se projeví involuce výrazněji než na straně vestibulární. Změna úhlu ovlivní významně tvar retromolárního trigona. Tato oblast podléhá postupně depresi kosti, kompaktní ploténka klesá do hloubky a povrch trigona se výrazně přiblíží k zakřivenému úseku canalis mandibulae. Proto není trigonum retromolare stařeckých bezzubých čelistí vhodným místem pro zavádění dentálních implantátů. Po ztrátě zubů dochází na ramus mandib. k resorpci kosti až do úrovně svalových úponů, tedy např. až ke crista mylohyoidea. Spina mentalis přitom zbytňuje. Resorpce kosti jde tedy hlouběji, než je dolní apikální baze, takže se na horní ploše těla mandibuly může objevit v určitém rozsahu canalis mandibulae i foramen mentale. To je komplikace při výrobě a nošení úplných zubních náhrad. § sharp mylohyoid linea § enlarged mental spinae Resorption of alveolar bone Decreased bone of alveolar process is noted when there is inactivity of tooth mandibula 006 § The portion of the jaw bone that contains the roots of the mandibular teeth and the alveoli in which they are suspended § The development is dependent on tooth eruption and its maintenance on tooth retention § Is composed of compact bone (0.1-0.8 mm) that encloses the spongiosa Alveolar process mandibula 005 Compact bone (lingual cortical plate) Compact bone (labial cortical plate) Spongy bone Alveolus § Is composed of a thin plate of cortical bone with numerous perforations (or cribriform plate) that allow the passage of blood vessels between the bone marrow spaces and the periodontal ligament § § The coronal rim of the alveolar bone forms the alveolar crest, which generally parallels the cemento-enamel junction at a distance of 1-2 mm apical to it Alveolus Figure_09-17 Bundle bone § Radiographically, the bundle bone is the lamina dura = the inner portion of the bone of the alveolus that surrounds teeth and into which the collagen fibers of the periodontal ligament are embedded mandibula 005 Alveolus (compact bone) Septum interalveolare (spongy bone) 0.7-14 mm § The whole life the bone keeps the potential to reconstruction § § Bone is resorbed on the side of pressure and opposed on the site of tension - regenerated § § Movement of a tooth by extrusion involves applying traction forces in all regions of the periodontal ligament to stimulate marginal apposition of crestal bone Reconstruction of alveolar bone Important for anesthesia, extraction, injury, implantology, endodontic treatment ... 1. The transverse asymmetry of alveolus 2. The rate of the spongy and the compact bone 3. The relationship the roots the lower jaw to neighbouring structures Dentoalveolar topography mandibula 017 1. The transverse asymmetry of alveolus § The dental and skeletal arch are asymmetric ! § § Roots of the teeth: 1-5 eccentric in the vestibular direction 6 in alveolar process axis 7-8 eccentric into oral direction 2. The rate of the spongy and the compact bone § The layer of compact bone is thicker than in the upper jaw § § Roots of the incisivi and canini teeth are surrounded by the compact bone § § Roots of the premolars and molars are surrounded by the pre- and retroalveolar spongy bone that is thin, fragible 1-č Incisivi, Canini CAVE! § Fractures by extraction ! § Root of the 3nd tooth – fracture of mandible ! Compact bone only 6-č Molars 4-č Premolars Compact bone and variable thickness of spongy bone bucally and lingually (linea mylohyoidea) mandibula 021 Spongy bone is distally to 8 3. The relationship the roots the lower jaw to neighbouring structures Canalis mandibulae (incisivus, mentalis) figure_1 CAVE! § Dehiscence of the canal and the alveolus § Implants Variable layer of spongy bone between canals and teeth´s roots CAVE! The endodontic treatment Nerve and blood supply Image86 Alveolar inferior nerve mental nerve incisive nerves Mylohyoid nerve Buccal nerve Lingual nerve Trigeminal nerve cap_147543 has traditionally been considered a motor nerve, but it can convey impulses from the incisive and canine teeth and gingiva ! 1. Mylohyoid nerve Variation Important for anesthesy ! Dissection of the mandibular nerve in a cadaver of southern Chinese origin showed the mylohyoid nerve arising from the lingual nerve and the buccal nerve arising from the inferior alveolar nerve within the mandibular ramus. It is estimated that this variation in the origin of the buccal nerve occurs in 6.1% of the southern Chinese population. Indian J Dent Res. 2010 Jan-Mar;21(1):141-2. An unusual communication between the mylohyoid and lingual nerves in man: its significance in lingual nerve injury. Potu BK, D'Silva SS, Thejodhar P, Jattanna NC. Department of Anatomy, Kasturba Medical College, Manipal University, Karnataka 576 104, India. Abstract The mylohyoid nerve is the branch of the inferior alveolar nerve (IAN) which arises above the mandibular foramen. An abnormal communication between the mylohyoid nerve and lingual nerve (LN) was noted during the routine dissection of a male cadaver. Communicating branches between IAN and LN have been identified as a possible explanation for the inefficiency of mandibular anesthesia. The communication between mylohyoid and lingual nerve was found in this case after the LN passes in close relation to third molar tooth, which makes it more susceptible to injury during third molar extractions. Rom J Morphol Embryol. 2009;50(1):145-6. Unusual communication between the lingual nerve and mylohyoid nerves in a South Indian male cadaver: its clinical significance. Potu BK, Pulakunta T, Ray B, Rao MS, Bhat KM, D'Silva SS, Nayak SR. Department of Anatomy, Centre for Basic Sciences, Kasturba Medical College, Manipal University, Manipal, Karnataka, India. potukumar2000@gmail.com Abstract It is well known that variations in the branching pattern of the mandibular nerve frequently account for the failure to obtain adequate local anesthesia in routine oral and dental procedures, and also for the unexpected injury to branches of the nerves during surgery. During our routine dissection, we found the presence of a communicating branch between the mylohyoid and lingual nerves in a middle aged male cadaver. We also discussed its clinical and surgical implications in this report After branching from the inferior alveolar nerve, the nerve to the mylohyoid courses anteriorly along the lingual surface of the mandible in the mylohyoid groove. This groove runs parallel to the mandibular canal, traveling medial to it for 20 mm prior to terminating inferior to the posterior edge of the mylohyoid line. After exiting the mylohyoid groove or canal, motor fibers from the nerve to the mylohyoid travel between the mylohyoid muscle and the anterior belly of digastric muscle. The nerve to the mylohyoid innervates the mylohyoid muscle on its infero-lateral superficial surface, whereas it supplies the anterior belly of digastric on its supero-medial deep surface. Often a branch from the nerve to the mylohyoid pierces the mylohyoid muscle and joins the lingual nerve. Although the nerve to the mylohyoid has traditionally been considered a motor nerve, it has been suggested that sensory fibers carried by the nerve supply the skin over the chin and mandibular teeth as well as medial portions of the submandibular triangle. However, the nerve to the mylohyoid may escape anesthesia AIN because it may arise at some distance higher than the mandibular foramen. The point from which the nerve to the mylohyoid arises from the inferior alveolar nerve demonstrates significant variability. 2. Sometimes the branches entering separated bony channels laterocranial of mandible foramen and M3, M2 The nerves entering the mandible at the retromolar fossa cap_147544 Inferior alveolar artery (maxillary artery) mylohyoid a. dent. et interalveolar a. mental a. incisive a. Facial artery submental a. Lingual artery sublingual a. ØThe pictures used in this lecture were taken from following sources: Ø ØČihák: Anatomie I, II, III. ØAtlas der Anatomie des Menschen/Sobotta. Putz,R., und Pabst,R. 20. Auflage. München:Urban & Schwarzenberg, 1993 ØNetter: Interactive Atlas of Human Anatomy ØNaňka, Elišková: Přehled anatomie. Galén, Praha 2009 ØDrake et al: Gray´s Anatomy for Students. 2010 ØGrim, Druga et al.: Základy Anatomie 1, Galén, Praha 2001 ØReferences: •Čihák, R.: Anatomie 1,2,3, Praha, Grada, 2001 •Netter, F.: Atlas of HumanAnatomy, 4th ed., Elseviesr, USA, 2006 •Naňka, Elišková: Přehled anatomie. Galén, Praha 2009 •Seidl et al.: Radiologie pro studium i praxi, Grada publishing, 2013 •Mrázková, Doskočil: Klinická anatomie pro stomatology, Alberta, Praha, 1994 •Brand, Isselhard: Anatomy of orofacial structures, 8th edition, Elsevier, USA, 2019 •Fehrenbach, Herring: Illustrated anatomy of the head and neck, 5th edition, Elsevier, USA, 2017 •Moore, Dalley: Clinically oriented anatomy, 5th edition, USA, 2006 Ø