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
folds.
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 centre 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
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 accessory
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.
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, 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 .
Latergreater development of maxilla takes place .
8 weeks of post conception maxilla overlaps the mandible
11 week- relatively greater growth of mandible results in the approx
equal size of the upper and the lower jaws.
13th and 20th weeks- mand growth lags behind max growth 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:
Pierre robin syndrome
cri du chat
Treacher collins syndrome
Progeria
downs syndrome
Hallermann-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
coronoid
Condylar
head
neck
Pterygoid
fovea
Anterior ramus
and coronoid
notch
Unerupted 3
molar
rd
Alveolar part
Oblique line
body
Mental foramen
Base of mandible
Mental tubercle
Mental
Coronoid
process
Mandibular
notch
ramus
angle
ramus
lingula
Sublingual
fossa
Pulaosterior border
of ramus
Mandibular
foramen
Superior and
inferior
mental
spines
Mylohyoid groove
Mylohyoid
line
Digastric fossa
Angle
Submandibular
fossa
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
Sphenomandibular
ligament
mylohyoid
Stylomanbular
ligament
genioglossus
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
Origin : Bone of the temporal
fossa and temporal fascia.
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:
lower head:
Upper head
Insertion :Capsule of the TMJ
joint in the region of attachment to
articular disc and pterygoid fovea
on the neck of the mandible .
Lower head
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.
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)
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 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.
The condylar region- most common
The angle 2nd most
Multiple fracture more common
2.
3.
20
21
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, subluxation
, or dislocation over the
eminentia occurs.
fracture
Extra capsular or sub-
condylar fracture.
Intracapsular Head
fractured within joint
cavity often comminuted
Sub condylar
fracture:Result of voilence to
the mental
prominence or
contralateral body of
the mandible.
The line of fracture, very
significantly ,lies just
above the posteriosuperior 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:- 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
inco-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
insertion 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
Favourable and unfavourable Fractures
Vertically
favourable
fracture
Lingual
plate
Vertically
unfavourable fracture
Buccal
plate
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
fractures
Antero-medial deviation or dislocation
of condyle.
Gross anterior open bite.
Bilateral
angle
fractures- Two posterior
fragments 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---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, 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.
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.
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
